Basic Information
Provider Information | |||||||||
NPI: | 1730764697 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MASSEY AVENUE ALF OPERATING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 317 MONMOUTH AVE # 201 | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | NJ | ||||||||
PostalCode: | 087013209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8482102175 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 414 MASSEY AVE | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN VIEW | ||||||||
State: | AR | ||||||||
PostalCode: | 725606132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8702695845 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2021 | ||||||||
LastUpdateDate: | 08/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GANZ | ||||||||
AuthorizedOfficialFirstName: | YISROEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INCORPORATOR | ||||||||
AuthorizedOfficialTelephone: | 7325232395 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.