MEDICARE: ASSISTED LIVING OF WALL TOWNSHIP, 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	310400000X	Assisted Living Facility	1EGWIO	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	:	1942425897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASSISTED LIVING OF WALL TOWNSHIP, LLC

Provider Business Mailing Address
First Line	:	2018 STATE ROUTE 35
Second Line	:
City	:	SPRING LAKE
State	:	NJ
Zip	:	07762-2558
Country	:	US
Telephone Number	:	732-282-1014
Fax Number	:	732-282-1050

Provider Business Practice Location Address
First Line	:	2018 STATE ROUTE 35
Second Line	:
City	:	SPRING LAKE
State	:	NJ
Zip	:	07762-2558
Country	:	US
Telephone Number	:	732-282-1014
Fax Number	:	732-282-1050

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. NANCY RENEHAN
Credential	:	NJCALA
Telephone Number	:	732-282-1014

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	08/22/2020

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