Basic Information
Provider Information | |||||||||
NPI: | 1861817306 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BLUEBERRY HILL OPERATOR LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BLUEBERRY HILL REHABILITATION AND HEALTHCARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 575 ROUTE 70 | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | BRICK | ||||||||
State: | NJ | ||||||||
PostalCode: | 087234042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7326065973 | ||||||||
FaxNumber: | 7326082976 | ||||||||
Practice Location | |||||||||
Address1: | 75 BRIMBAL AVE | ||||||||
Address2: |   | ||||||||
City: | BEVERLY | ||||||||
State: | MA | ||||||||
PostalCode: | 019156009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9789272020 | ||||||||
FaxNumber: | 7326082976 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2014 | ||||||||
LastUpdateDate: | 05/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROKOWSKY | ||||||||
AuthorizedOfficialFirstName: | YITZCHOK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7324156016 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | MA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.