Basic Information
| Provider Information | |||||||||
| NPI: | 1720096035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HW WEIDCO REN LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH JERSEY EXTENDED CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 UNIVERSITY PLZ | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076016201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014886789 | ||||||||
| FaxNumber: | 2014887734 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 MANHEIM AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083022114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564552100 | ||||||||
| FaxNumber: | 8564550960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 12/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | WEISZ | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2014886789 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060602 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4473701 | 05 | NJ | MEDICAID |