Basic Information
| Provider Information | |||||||||
| NPI: | 1649206327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 3809 BAYSHORE ROAD OPERATIONS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | VICTORIA MANOR | ||||||||
| 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: | 3809 BAYSHORE RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CAPE MAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082043259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098980677 | ||||||||
| FaxNumber: | 6098981186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 06/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | KIELER | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5054684742 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENESIS NJ HOLDINGS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060508 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 316929 | 01 | US FAMILY HEALTH PLAN | OTHER | 62-1518645 | 01 | CONSUMER HEALTH NETWORK | OTHER | 489813 | 01 | AETNA-HMO | OTHER | 4471709 | 01 | UNISYS # | OTHER | 62-1518645 | 01 | AETNA-NONHMO | OTHER | 0006179000 | 01 | AMERIHEALTH | OTHER | 0261173 | 01 | NJ | MOLINA # | OTHER | 315281 | 01 | HORIZON - SNF | OTHER | 62-1518645 | 01 | HNFS-TRICARE | OTHER | 62-1518645 | 01 | CIGNA-NJ | OTHER | 000852 | 01 | HORIZON - SUB | OTHER | 05400 | 05 | NJ | MEDICAID | 62-1518645 | 01 | HCPC | OTHER |