Healthcare Provider Details

I. General information

NPI: 1114641776
Provider Name (Legal Business Name): 2050 TREVORTON ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 TREVORTON RD
COAL TOWNSHIP PA
17866-9405
US

IV. Provider business mailing address

1105 E COUNTY LINE RD STE 201
LAKEWOOD NJ
08701-2122
US

V. Phone/Fax

Practice location:
  • Phone: 570-644-4400
  • Fax:
Mailing address:
  • Phone:
  • 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: BLIMI AVIV
Title or Position: DIRECTOR OF AR
Credential:
Phone: 973-285-2893