Healthcare Provider Details

I. General information

NPI: 1932108693
Provider Name (Legal Business Name): 11 HISTORY LANE OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HISTORY LANE
JACKSON NJ
08527
US

IV. Provider business mailing address

11 HISTORY LANE
JACKSON NJ
08527
US

V. Phone/Fax

Practice location:
  • Phone: 732-367-6600
  • Fax: 732-905-9641
Mailing address:
  • Phone: 732-367-6600
  • Fax: 732-905-9641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number0088447
License Number StateNJ

VIII. Authorized Official

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