Healthcare Provider Details

I. General information

NPI: 1861560187
Provider Name (Legal Business Name): FS LEISURE PARK TENANT TRUST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HIGHWAY 70
LAKEWOOD NJ
08701-5949
US

IV. Provider business mailing address

1400 HIGHWAY 70
LAKEWOOD NJ
08701-5949
US

V. Phone/Fax

Practice location:
  • Phone: 732-370-0444
  • Fax: 732-370-1783
Mailing address:
  • Phone: 732-370-0444
  • Fax: 732-370-1783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE E POTTER
Title or Position: PRESIDENT & CHIEF EXECUTIVE OFFICER
Credential:
Phone: 617-796-8387