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General NPI Number Information
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NPI Number | 1619362563
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Entity Type | Organization
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Legal Business Name | 493 BLACK OAK RIDGE ROAD, LLC
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Dates
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Enumeration Date | 03/30/2015
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Last Update Date | 03/30/2015
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Provider Practice Location Address
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Address Line | 493 BLACK OAK RIDGE RD
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City | WAYNE
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State | NJ
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Zip | 07470-6501
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Country | US
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Telephone | 973-692-9500
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Fax |
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Provider Business Mailing Address
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Address Line | 493 BLACK OAK RIDGE RD
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City | WAYNE
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State | NJ
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Zip | 07470-6501
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Country | US
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Telephone | 973-692-9500
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT & G.C.
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Name | ANDROSKY ALBERTO LUGO
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Credential | ESQ
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Telephone | 201-242-4006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | VQXWIZ
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License Number State | NJ
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