1063742708 NPI number — RC OPERATORS, LLC (D.B.A. WILLOW TERRACE)

Table of content: (NPI 1063742708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063742708 NPI number — RC OPERATORS, LLC (D.B.A. WILLOW TERRACE)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RC OPERATORS, LLC (D.B.A. WILLOW TERRACE)
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WILLOW TERRACE NSG CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063742708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 MARLBORO ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOOD-RIDGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-635-1195
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE PENN BOULEVARD
Provider Second Line Business Practice Location Address:
PENN TOWER
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19144-4206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-951-8656
Provider Business Practice Location Address Fax Number:
215-849-1946
Provider Enumeration Date:
12/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RINGKAMP
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
215-951-8656

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  072102 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1024679250001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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