Basic Information
| Provider Information | |||||||||
| NPI: | 1194852327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAZLET MANOR ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REGENCY PARK NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 643 CROSS STREET | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327309280 | ||||||||
| FaxNumber: | 7327308407 | ||||||||
| Practice Location | |||||||||
| Address1: | 3325 HIGHWAY 35 | ||||||||
| Address2: | |||||||||
| City: | HAZLET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077301552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322645800 | ||||||||
| FaxNumber: | 7322647995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | STEFANSKY | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7327309280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 55C000 | NJ | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 061303 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4490207 | 05 | NJ | MEDICAID |