Healthcare Provider Details

I. General information

NPI: 1528577293
Provider Name (Legal Business Name): 1165 EASTON AVENUE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 EASTON AVE
SOMERSET NJ
08873-1613
US

IV. Provider business mailing address

1165 EASTON AVE
SOMERSET NJ
08873-1613
US

V. Phone/Fax

Practice location:
  • Phone: 732-246-4100
  • Fax:
Mailing address:
  • Phone: 732-246-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number00000
License Number StateNJ

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: VP GEN COUNSEL ASST SECY
Credential:
Phone: 505-468-4742