Healthcare Provider Details

I. General information

NPI: 1306182159
Provider Name (Legal Business Name): 521 PINE BROOK OPERATING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 PINE BROOK RD
LINCOLN PARK NJ
07035-1801
US

IV. Provider business mailing address

499 PINE BROOK RD
LINCOLN PARK NJ
07035-1804
US

V. Phone/Fax

Practice location:
  • Phone: 973-696-3300
  • Fax:
Mailing address:
  • Phone: 973-696-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number061408
License Number StateNJ

VIII. Authorized Official

Name: CHARLES-EDOUARD GROS
Title or Position: MANAGING MEMBER
Credential:
Phone: 973-696-3300