Basic Information
| Provider Information | |||||||||
| NPI: | 1316362809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 200 MARTER AVENUE OPERATIONS LLC | ||||||||
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| OtherOrganizationName: | POWERBACK REHABILITATION MOORESTOWN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104446350 | ||||||||
| FaxNumber: | 6104444395 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MARTER AVENUE | ||||||||
| Address2: | |||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104446350 | ||||||||
| FaxNumber: | 6104444395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2014 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | HAGER | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | V. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6104446350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENESIS NJ HOLDINGS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060216 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.