Provider Demographics
NPI:1346371812
Name:LAURELTON VILLAGE
Entity Type:Organization
Organization Name:LAURELTON VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL RESIDENT ACCOUNTING MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRAMELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-813-2000
Mailing Address - Street 1:525 FELLOWSHIP RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3415
Mailing Address - Country:US
Mailing Address - Phone:856-813-2000
Mailing Address - Fax:856-813-2020
Practice Address - Street 1:475 JACK MARTIN BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7732
Practice Address - Country:US
Practice Address - Phone:732-458-6600
Practice Address - Fax:732-458-2674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ061532314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4492706Medicaid
NJ315274AMedicare ID - Type Unspecified