1922015122 NPI number — SJF CCRC, INC

Table of content: (NPI 1922015122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922015122 NPI number — SJF CCRC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SJF CCRC, INC
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:
Provider Other Organization Name Type Code:
6
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:
1922015122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 LAUREL OAK RD
Provider Second Line Business Mailing Address:
EXECUTIVE OFFICES
Provider Business Mailing Address City Name:
VOORHEES
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08043-4344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-679-2210
Provider Business Mailing Address Fax Number:
856-667-5042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 LAUREL OAK RD
Provider Second Line Business Practice Location Address:
LIONS GATE HEALTH CENTER
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-4363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-679-2270
Provider Business Practice Location Address Fax Number:
856-667-5042
Provider Enumeration Date:
08/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
856-679-2211

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  04A003 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 311500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 04002 , 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: 0124737 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".