Basic Information
| Provider Information | |||||||||
| NPI: | 1396037149 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLY NAME MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VILLA MARIE CLAIRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 TEANECK RD | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2012276055 | ||||||||
| FaxNumber: | 2015307900 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 SADDLE RIVER RD | ||||||||
| Address2: | |||||||||
| City: | SADDLE RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018333188 | ||||||||
| FaxNumber: | 2015307900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2018337016 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOLY NAME MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 02C011 | NJ | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 0262749 | 05 | NJ | MEDICAID |