Basic Information
Provider Information | |||||||||
NPI: | 1164842183 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 1419 ROUTE 9 NORTH OPERATIONS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EASTERN SHORE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 E STATE ST | ||||||||
Address2: |   | ||||||||
City: | KENNETT SQUARE | ||||||||
State: | PA | ||||||||
PostalCode: | 193483109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104446350 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1419 N ROUTE 9 | ||||||||
Address2: |   | ||||||||
City: | CAPE MAY COURT HOUSE | ||||||||
State: | NJ | ||||||||
PostalCode: | 082101415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6094652260 | ||||||||
FaxNumber: | 6094652680 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2014 | ||||||||
LastUpdateDate: | 07/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAGER | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: | V. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6104446350 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GENESIS OPERATIONS VI LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060506 | NJ | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.