MEDICARE: LEISURE CHATEAU ACQUISITION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	061515	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5952870001	OTHER	NJ	MEDICARE NHIC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790772267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEISURE CHATEAU ACQUISITION LLC

Provider Business Mailing Address
First Line	:	962 RIVER AVE
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-5605
Country	:	US
Telephone Number	:	732-370-8600
Fax Number	:	732-370-8676

Provider Business Practice Location Address
First Line	:	962 RIVER AVE
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-5605
Country	:	US
Telephone Number	:	732-370-8600
Fax Number	:	732-370-8676

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. NORMAN ROKEACH
Credential	:	LNHA
Telephone Number	:	732-370-8600

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	04/12/2010

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Directions to “LEISURE CHATEAU ACQUISITION LLC ” Practice Location

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