Provider Demographics
NPI:1447384680
Name:COUNTY OF GLOUCESTER
Entity Type:Organization
Organization Name:COUNTY OF GLOUCESTER
Other - Org Name:SHADY LANE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCAFFIDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-423-5318
Mailing Address - Street 1:254 COUNTY HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08020-1395
Mailing Address - Country:US
Mailing Address - Phone:856-423-5318
Mailing Address - Fax:856-423-3634
Practice Address - Street 1:256 COUNTY HOUSE RD
Practice Address - Street 2:
Practice Address - City:CLARKSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08020-1395
Practice Address - Country:US
Practice Address - Phone:856-423-5318
Practice Address - Fax:856-423-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060805314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4478703Medicaid
NJ315405Medicare ID - Type Unspecified