Basic Information
| Provider Information | |||||||||
| NPI: | 1386893337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFE ST. FRANCIS CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7500 K JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | BORDENTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085052242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095995433 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7500 K JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | BORDENTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085052242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095995433 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 10/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | VIGGIANO | ||||||||
| AuthorizedOfficialFirstName: | JILL ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6095995475 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. FRANCIS MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 0169129 | 05 | NJ | MEDICAID | H1234 | 01 | MEDICARE H NUMBER | OTHER |