Provider Demographics
NPI:1023009156
Name:WILEY MISSION
Entity Type:Organization
Organization Name:WILEY MISSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-983-0411
Mailing Address - Street 1:99 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2122
Mailing Address - Country:US
Mailing Address - Phone:856-983-0411
Mailing Address - Fax:856-985-4655
Practice Address - Street 1:99 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2122
Practice Address - Country:US
Practice Address - Phone:856-983-0411
Practice Address - Fax:856-985-4655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ153335311Z00000X
NJ030307314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4466900Medicaid
NJ315418Medicare ID - Type Unspecified