Basic Information
| Provider Information | |||||||||
| NPI: | 1821532946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKILES AVENUE AND STERLING DRIVE URBAN RENEWAL OPERATIONS LLC | ||||||||
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| OtherOrganizationName: | POWERBACK REHABILITATION PISCATAWAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104446350 | ||||||||
| FaxNumber: | 6104444395 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 STERLING DRIVE | ||||||||
| Address2: | |||||||||
| City: | PISCATAWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088541234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054684742 | ||||||||
| FaxNumber: | 5054688742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2016 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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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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| AuthorizedOfficialCredential: | JD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0000000 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.