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NPI Code Detail

MEDICARE: 493 BLACK OAK RIDGE ROAD, LLC

MEDICARE: 493 BLACK OAK RIDGE ROAD, 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
1310400000XAssisted Living FacilityVQXWIZNJ

General Provider Information

NPI Number : 1619362563
Entity Type Code : Organization
Provider Name (Legal Business Name) : 493 BLACK OAK RIDGE ROAD, LLC
Provider Business Mailing Address
First Line : 493 BLACK OAK RIDGE RD
Second Line :
City : WAYNE
State : NJ
Zip : 07470-6501
Country : US
Telephone Number : 973-692-9500
Fax Number :
Provider Business Practice Location Address
First Line : 493 BLACK OAK RIDGE RD
Second Line :
City : WAYNE
State : NJ
Zip : 07470-6501
Country : US
Telephone Number : 973-692-9500
Fax Number :
Authorized Official
Title or Position : EXECUTIVE VICE PRESIDENT & G.C.
Name : ANDROSKY ALBERTO LUGO
Credential : ESQ
Telephone Number : 201-242-4006
Provider Enumeration Date : 03/30/2015
Last Update Date : 03/30/2015

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