MEDICARE: 11 HISTORY LANE OPERATING COMPANY, 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	385H00000X	Respite Care	0088447	NJ
2	314000000X	Skilled Nursing Facility		NJ

Other Identifiers

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

General Provider Information

NPI Number	:	1932108693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	11 HISTORY LANE OPERATING COMPANY, LLC

Provider Business Mailing Address
First Line	:	11 HISTORY LANE
Second Line	:
City	:	JACKSON
State	:	NJ
Zip	:	08527
Country	:	US
Telephone Number	:	732-367-6600
Fax Number	:	732-905-9641

Provider Business Practice Location Address
First Line	:	11 HISTORY LANE
Second Line	:
City	:	JACKSON
State	:	NJ
Zip	:	08527
Country	:	US
Telephone Number	:	732-367-6600
Fax Number	:	732-905-9641

Authorized Official
Title or Position	:	EXECUTIVE VP & GENERAL COUNSEL
Name	:	MR. A. ALBERTO LUGO
Credential	:
Telephone Number	:	201-242-4000

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	08/13/2015

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