Healthcare Provider Details

I. General information

NPI: 1154454023
Provider Name (Legal Business Name): VAN DYK AT BALD EAGLE COMMONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 CAHILL CROSS RD
WEST MILFORD NJ
07480-1947
US

IV. Provider business mailing address

644 GOFFLE RD
HAWTHORNE NJ
07506-3452
US

V. Phone/Fax

Practice location:
  • Phone: 201-689-7979
  • Fax: 973-304-2046
Mailing address:
  • Phone: 201-689-7979
  • Fax: 973-304-2046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number70A000
License Number StateNJ

VIII. Authorized Official

Name: MR. CHARLES H SHOTMEYER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 201-689-7979