MEDICARE: SOUTH CENTER STREET NURSING HOME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	062209	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245272723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH CENTER STREET NURSING HOME, LLC

Provider Business Mailing Address
First Line	:	14C 53RD ST STE 220
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11232-2646
Country	:	US
Telephone Number	:	718-567-0400
Fax Number	:	718-567-0600

Provider Business Practice Location Address
First Line	:	135 S CENTER ST
Second Line	:
City	:	ORANGE
State	:	NJ
Zip	:	07050-3522
Country	:	US
Telephone Number	:	973-266-3200
Fax Number	:	973-266-3302

Authorized Official
Title or Position	:	CORPORATE OFFICER
Name	:	SAM STERN
Credential	:
Telephone Number	:	718-567-9459

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	03/11/2026

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