Provider Demographics
NPI:1407852833
Name:CANTERBURY AT CEDAR GROVE CARE & REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:CANTERBURY AT CEDAR GROVE CARE & REHABILITATION CENTER LLC
Other - Org Name:CEDAR GROVE MANOR
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP FINCANCE AND CENSUS DEVELOPEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CONDORELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-767-0100
Mailing Address - Street 1:100 MCCLELLEN ST
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07648-1555
Mailing Address - Country:US
Mailing Address - Phone:201-767-0100
Mailing Address - Fax:201-881-1191
Practice Address - Street 1:398 POMPTON AVE
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1813
Practice Address - Country:US
Practice Address - Phone:973-239-7600
Practice Address - Fax:973-239-8725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060729314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8864501Medicaid
NJ8864501Medicaid