Provider Demographics
NPI:1316362809
Name:200 MARTER AVENUE OPERATIONS LLC
Entity Type:Organization
Organization Name:200 MARTER AVENUE OPERATIONS LLC
Other - Org Name:POWERBACK REHABILITATION MOORESTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:V
Authorized Official - Last Name:HAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-444-6350
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:610-444-6350
Mailing Address - Fax:610-444-4395
Practice Address - Street 1:200 MARTER AVENUE
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3114
Practice Address - Country:US
Practice Address - Phone:610-444-6350
Practice Address - Fax:610-444-4395
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS NJ HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060216314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility