Healthcare Provider Details

I. General information

NPI: 1316114861
Provider Name (Legal Business Name): CPL (WILLOW CREEK) LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 EASTON AVE
SOMERSET NJ
08873-1613
US

IV. Provider business mailing address

538 PRESTON AVE SUITE 270
MERIDEN CT
06450-4851
US

V. Phone/Fax

Practice location:
  • Phone: 732-246-4100
  • Fax: 732-246-3926
Mailing address:
  • Phone: 203-608-6100
  • Fax: 203-639-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number061808
License Number StateNJ

VIII. Authorized Official

Name: CAROLE M SCILLIA
Title or Position: LLC MANAGER
Credential:
Phone: 203-608-6134