Provider Demographics
NPI:1144805003
Name:SOUTH DIXIELAND ROAD OPERATING LLC
Entity Type:Organization
Organization Name:SOUTH DIXIELAND ROAD OPERATING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR
Authorized Official - Prefix:
Authorized Official - First Name:YISROEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GANZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-523-2395
Mailing Address - Street 1:317 MONMOUTH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3209
Mailing Address - Country:US
Mailing Address - Phone:848-210-2175
Mailing Address - Fax:
Practice Address - Street 1:1513 S DIXIELAND RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-4935
Practice Address - Country:US
Practice Address - Phone:479-636-5841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility