Healthcare Provider Details

I. General information

NPI: 1962410365
Provider Name (Legal Business Name): MR OF ROSEWOOD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY PLZ SUITE 206
HACKENSACK NJ
07601-6201
US

IV. Provider business mailing address

1 UNIVERSITY PLZ SUITE 206
HACKENSACK NJ
07601-6201
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-6789
  • Fax:
Mailing address:
  • Phone: 201-488-6789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number060307
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4466306
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: FISCHEL RISPLER
Title or Position: MEMBER
Credential:
Phone: 201-488-6789