Provider Demographics
NPI:1407124837
Name:INNOVA GLOUCESTER DEPTFORD BRIDGE OPERATIONS LLC
Entity Type:Organization
Organization Name:INNOVA GLOUCESTER DEPTFORD BRIDGE OPERATIONS LLC
Other - Org Name:DEPTFORD CENTER FOR REHABILITATION & HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-931-9700
Mailing Address - Street 1:4770 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1104
Mailing Address - Country:US
Mailing Address - Phone:718-931-9700
Mailing Address - Fax:
Practice Address - Street 1:1511 CLEMENTS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-3007
Practice Address - Country:US
Practice Address - Phone:718-931-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ04478207Medicaid
NJ04478207Medicaid