MEDICARE: PERIDOT ASSISTED LIVING

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1629694047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIDOT ASSISTED LIVING

Provider Business Mailing Address
First Line	:	2408 HIGH ST
Second Line	:
City	:	PORT NORRIS
State	:	NJ
Zip	:	08349-3239
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2408 HIGH ST
Second Line	:
City	:	PORT NORRIS
State	:	NJ
Zip	:	08349-3239
Country	:	US
Telephone Number	:	732-429-4989
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. RAJ BHARADWAJ
Credential	:
Telephone Number	:	732-429-4989

Provider Enumeration Date	:	06/22/2020
Last Update Date	:	06/22/2020

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Directions to “PERIDOT ASSISTED LIVING ” Practice Location

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