=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922689843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE CARE AT INGLEMOOR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2021
-----------------------------------------------------
Last Update Date | 04/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 GRAND AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-4356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-586-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 GRAND AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-4356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-586-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED SIGNER
-----------------------------------------------------
Name | SHALOM STEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-313-0880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------