Basic Information
| Provider Information | |||||||||
| NPI: | 1386699346 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWEST TOTAL CARE CENTER ASSOCIATES, L.P. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRAKELEY PARK CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254436 | ||||||||
| FaxNumber: | 6109254351 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 RED SCHOOL LN | ||||||||
| Address2: | |||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088652276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088592800 | ||||||||
| FaxNumber: | 9088594532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | DROPESKEY | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6109254231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 953335 | NJ | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | 062106 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0004475000 | 01 | AMERIHEALTH-MANAGED CARE | OTHER | 0004475000 | 01 | IBC-MANAGED CARE | OTHER | 0004475000 | 01 | IBC-TRADITIONAL | OTHER | 000822 | 01 | HORIZON - SUB | OTHER | 317107 | 01 | US FAMILY HEALTH PLAN | OTHER | 0004475000 | 01 | AMERIHEALTH-TRADITIONAL | OTHER | 2049077 | 01 | AETNA-HMO | OTHER | 315316 | 01 | HORIZION - SNF | OTHER | 5222702 | 01 | NJ | UNISYS | OTHER | 21620 | 05 | NJ | MEDICAID |