Basic Information
| Provider Information | |||||||||
| NPI: | 1306987722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARTWYCK AT OAKTREE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JFK HARTWYCK AT EDISON ESTATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 98 JAMES ST | ||||||||
| Address2: | FOURTH FLOOR | ||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088203902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323217000 | ||||||||
| FaxNumber: | 7323210995 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 BRUNSWICK AVE | ||||||||
| Address2: | |||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088172507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329851500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 08/15/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANKEY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT LONG TERM CAR | ||||||||
| AuthorizedOfficialTelephone: | 7323217000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 061205 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4484801 | 05 | NJ | MEDICAID | 12200 | 05 | NJ | MEDICAID |