Basic Information
| Provider Information | |||||||||
| NPI: | 1114962073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANOR CARE-WEST DEPTFORD OF PAULSBORO NJ LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANORCARE HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192525500 | ||||||||
| FaxNumber: | 8773859446 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 JESSUP RD | ||||||||
| Address2: | |||||||||
| City: | PAULSBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080661921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568489551 | ||||||||
| FaxNumber: | 8568481817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4192525743 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060807 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4478509 | 05 | NJ | MEDICAID |