Healthcare Provider Details

I. General information

NPI: 1417611880
Provider Name (Legal Business Name): WAVERLY OPERATING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 10/22/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 E MAIN ST
WAVERLY VA
23890-3237
US

IV. Provider business mailing address

311 BLVD OF THE AMERICAS STE 504
LAKEWOOD NJ
08701
US

V. Phone/Fax

Practice location:
  • Phone: 804-834-3975
  • 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: TZVI ALTER
Title or Position: CEO
Credential:
Phone: 732-719-7270