=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376697748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AL I/EAST BRUNSWICK SENIOR HOUSING, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 SUMMERHILL RD
-----------------------------------------------------
City | EAST BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08816-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-613-1355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 SUMMERHILL RD
-----------------------------------------------------
City | EAST BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08816-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-613-1355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR REIMBURSEMENT MANAGER
-----------------------------------------------------
Name | MR. TONY J. HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-854-0830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 50A004
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------