Healthcare Provider Details

I. General information

NPI: 1073007928
Provider Name (Legal Business Name): BLACK HORSE ALR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6817 BLACK HORSE PIKE
EGG HARBOR TOWNSHIP NJ
08234
US

IV. Provider business mailing address

48 PAVILION AVE STE 2
LONG BRANCH NJ
07740-6413
US

V. Phone/Fax

Practice location:
  • Phone: 732-403-3151
  • Fax:
Mailing address:
  • Phone: 732-778-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: DREW BARILE
Title or Position: CEO
Credential:
Phone: 732-403-3151