Provider Demographics
NPI:1073505970
Name:69 MAPLE AVE INC
Entity Type:Organization
Organization Name:69 MAPLE AVE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-446-1804
Mailing Address - Street 1:104 PENSION RD
Mailing Address - Street 2:
Mailing Address - City:ENGLISHTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-8400
Mailing Address - Country:US
Mailing Address - Phone:732-446-1804
Mailing Address - Fax:732-446-0999
Practice Address - Street 1:69 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST MILFORD
Practice Address - State:NJ
Practice Address - Zip Code:07480-2707
Practice Address - Country:US
Practice Address - Phone:973-697-5640
Practice Address - Fax:973-697-8607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4496906Medicaid
NJ315276Medicare ID - Type Unspecified
NJ1167280001Medicare NSC