Basic Information
Provider Information | |||||||||
NPI: | 1376669911 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASSISTED LIVING CONCEPTS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | POST HOUSE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 W MICHIGAN STREET | ||||||||
Address2: | 9TH FLOOR | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 53203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4149088800 | ||||||||
FaxNumber: | 4149088212 | ||||||||
Practice Location | |||||||||
Address1: | 540 MULLICA HILL ROAD | ||||||||
Address2: |   | ||||||||
City: | GLASSBORO | ||||||||
State: | NJ | ||||||||
PostalCode: | 08360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8583070617 | ||||||||
FaxNumber: | 8565824471 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEVONOWICH | ||||||||
AuthorizedOfficialFirstName: | WALTER | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT AND CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 4149088800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 90110 | NJ | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 7154615 | 05 | NJ |   | MEDICAID |