Basic Information
| Provider Information | |||||||||
| NPI: | 1528627791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYVILLE FAIRPARK OPCO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 SYLVAN AVE STE 240 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD CLIFFS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076322700 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 307 N 5TH ST | ||||||||
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| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378042921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659830261 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | GORELICK | ||||||||
| AuthorizedOfficialFirstName: | BATYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF ADMINISTRATIVE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8659830261 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | N | Respite Care Facility | Respite Care | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.