Provider Demographics
NPI:1144217662
Name:SEACREST VILLAGE, INC
Entity Type:Organization
Organization Name:SEACREST VILLAGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-296-9292
Mailing Address - Street 1:1001 CENTER ST
Mailing Address - Street 2:PO BOX 1480
Mailing Address - City:LITTLE EGG HARBOR TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08087-1347
Mailing Address - Country:US
Mailing Address - Phone:609-296-9292
Mailing Address - Fax:609-296-0508
Practice Address - Street 1:1001 CENTER ST
Practice Address - Street 2:
Practice Address - City:LITTLE EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08087-1347
Practice Address - Country:US
Practice Address - Phone:609-296-9292
Practice Address - Fax:609-296-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ61522314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0077801Medicaid
NJ4494717Medicaid
NJ4494709Medicaid
NJ0077801Medicaid