=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972645034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIVE STAR ADULT MEDICAL DAY CARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 DEERFIELD TER
-----------------------------------------------------
City | LINDEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07036-5523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-486-5750
-----------------------------------------------------
Fax | 908-486-3325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 DEERFIELD TER
-----------------------------------------------------
City | LINDEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07036-5523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-486-5750
-----------------------------------------------------
Fax | 908-486-3325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MS. SVETLANA MARYASH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-486-5750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 908112
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------