Provider Demographics
NPI:1306004700
Name:ANDOVER NURSING & CONVALESCENT HOME
Entity Type:Organization
Organization Name:ANDOVER NURSING & CONVALESCENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:TURCO
Authorized Official - Last Name:KIPIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-460-8904
Mailing Address - Street 1:PO BOX 1279
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07821-1279
Mailing Address - Country:US
Mailing Address - Phone:973-383-6200
Mailing Address - Fax:
Practice Address - Street 1:99 MULFORD ROAD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:NJ
Practice Address - Zip Code:07848
Practice Address - Country:US
Practice Address - Phone:973-383-6200
Practice Address - Fax:973-940-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0081400Medicaid