Provider Demographics
NPI:1063496842
Name:COUNTRY ARCH CARE CENTER, LLC
Entity Type:Organization
Organization Name:COUNTRY ARCH CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-735-6600
Mailing Address - Street 1:114 PITTSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PITTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08867-4224
Mailing Address - Country:US
Mailing Address - Phone:908-735-6600
Mailing Address - Fax:908-735-7600
Practice Address - Street 1:114 PITTSTOWN RD
Practice Address - Street 2:
Practice Address - City:PITTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08867-4224
Practice Address - Country:US
Practice Address - Phone:908-735-6600
Practice Address - Fax:908-735-7600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ61006314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8531803Medicaid
315433Medicare ID - Type Unspecified