Provider Demographics
NPI:1306182159
Name:521 PINE BROOK OPERATING, LLC
Entity Type:Organization
Organization Name:521 PINE BROOK OPERATING, LLC
Other - Org Name:LINCOLN PARK RENAISSANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES-EDOUARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-696-3300
Mailing Address - Street 1:499 PINE BROOK RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1804
Mailing Address - Country:US
Mailing Address - Phone:973-696-3300
Mailing Address - Fax:
Practice Address - Street 1:521 PINE BROOK RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1801
Practice Address - Country:US
Practice Address - Phone:973-696-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:521 PINE BROOK VENTURES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ061408314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4491904Medicaid
NY01216893Medicaid
NJ4491904Medicaid