Basic Information
| Provider Information | |||||||||
| NPI: | 1700202751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 200 MARTER AVENUE OPERATIONS LLC | ||||||||
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| OtherOrganizationName: | POWERBACK REHABILITATION MOORESTOWN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 EAST STATE STREET | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193473109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104446350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 MARTER AVE | ||||||||
| Address2: | |||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562914800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2014 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| 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 | 0000NJ | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.