Healthcare Provider Details

I. General information

NPI: 1205792884
Provider Name (Legal Business Name): PORTAGE LAKES SKILLED NURSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2025
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LATHAM LN
NEW FRANKLIN OH
44319-4338
US

IV. Provider business mailing address

20 N COUNTY LINE RD
JACKSON NJ
08527-0247
US

V. Phone/Fax

Practice location:
  • Phone: 330-644-3914
  • Fax:
Mailing address:
  • Phone: 330-644-3914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: ISRAEL FELDHEIM
Title or Position: MANAGER
Credential:
Phone: 732-998-3617