1689910432 NPI number — 499 PINE BROOK OPERATING, LLC

Table of content: (NPI 1689910432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689910432 NPI number — 499 PINE BROOK OPERATING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
499 PINE BROOK OPERATING, LLC
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:
LINCOLN PARK CARE 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:
1689910432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
499 PINE BROOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07035-1804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-696-3300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
499 PINE BROOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN PARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07035-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-696-3300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GROS
Authorized Official First Name:
CHARLES-EDOUARD
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
973-696-3300

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  061409 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02621447 . This is a "MEDICAID- NY SPECIAL PROVIDER ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00310412 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4491203 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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