Basic Information
| Provider Information | |||||||||
| NPI: | 1851669287 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INNOVA BURLINGTON CHURCH OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOUNT LAUREL CENTER FOR REHABILITATION & HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4770 WHITE PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104701104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189319700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3718 CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080541104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562357100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2011 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | HAGLER | ||||||||
| AuthorizedOfficialFirstName: | DARYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7189319700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 04465903 | 05 | NJ | MEDICAID |