Provider Demographics
NPI:1073694295
Name:THE RESIDENCE AT LAKERIDGE LLC
Entity Type:Organization
Organization Name:THE RESIDENCE AT LAKERIDGE LLC
Other - Org Name:THE RESIDENCE AT TOMS RIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SABO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-806-4301
Mailing Address - Street 1:2145 WHITESVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755
Mailing Address - Country:US
Mailing Address - Phone:732-905-9222
Mailing Address - Fax:732-905-9442
Practice Address - Street 1:2145 WHITESVILLE ROAD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755
Practice Address - Country:US
Practice Address - Phone:732-905-9222
Practice Address - Fax:732-905-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ65A113310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0066192Medicaid