Basic Information
| Provider Information | |||||||||
| NPI: | 1063454494 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IRVINGTON HEALTHCARE PROVIDERS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHANCELLOR SPECIALTY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 170 53RD ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112324319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185670400 | ||||||||
| FaxNumber: | 7185670600 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 40TH ST | ||||||||
| Address2: | |||||||||
| City: | IRVINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071111184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733717878 | ||||||||
| FaxNumber: | 9733714081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STERN | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7185760400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060736 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5057906 | 05 | NJ | MEDICAID |