Provider Demographics
NPI:1568839710
Name:1165 EASTON AVENUE OPERATIONS LLC
Entity Type:Organization
Organization Name:1165 EASTON AVENUE OPERATIONS LLC
Other - Org Name:WILLOW CREEK REHABILITATION AND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:1165 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-1613
Mailing Address - Country:US
Mailing Address - Phone:732-246-4100
Mailing Address - Fax:732-246-4101
Practice Address - Street 1:1165 EASTON AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-1613
Practice Address - Country:US
Practice Address - Phone:732-246-4100
Practice Address - Fax:732-246-4101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-24
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
313M00000X
NJ314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility