Provider Demographics
NPI:1275674970
Name:CHESTNUT HILL RESIDENCE
Entity Type:Organization
Organization Name:CHESTNUT HILL RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK, JR.
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-777-7800
Mailing Address - Street 1:338 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-3158
Mailing Address - Country:US
Mailing Address - Phone:973-777-7800
Mailing Address - Fax:973-249-0623
Practice Address - Street 1:338 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-3158
Practice Address - Country:US
Practice Address - Phone:973-777-7800
Practice Address - Fax:973-249-0623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJHOT9MH310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8659907Medicaid