Basic Information
| Provider Information | |||||||||
| NPI: | 1033101795 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIRTUA HEALTH AND REHABILITATION CENTER AT MOUNT. HOLLY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 W STOW RD | ||||||||
| Address2: | STE 8 - ATTENTION: CHRISTINE GORDON | ||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080533160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563550655 | ||||||||
| FaxNumber: | 8563550621 | ||||||||
| Practice Location | |||||||||
| Address1: | 62 RICHMOND AVE | ||||||||
| Address2: | |||||||||
| City: | MT. HOLLY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092678800 | ||||||||
| FaxNumber: | 6099147878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 10/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8563550004 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VIRTUA HEALTH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060310 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4466403 | 05 | NJ | MEDICAID |