Basic Information
| Provider Information | |||||||||
| NPI: | 1780827030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FVE EC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024582094 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 LAUREL OAK RD | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565662340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2009 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | MACKEY | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6177968214 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FVE EC LLC | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 0356115 | 05 | NJ | MEDICAID |