Provider Demographics
NPI:1598323099
Name:SKILES AVENUE AND STERLING DRIVE URBAN RENEWAL OPERATIONS LLC
Entity Type:Organization
Organization Name:SKILES AVENUE AND STERLING DRIVE URBAN RENEWAL OPERATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:10 STERLING DR
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-4911
Mailing Address - Country:US
Mailing Address - Phone:732-917-2900
Mailing Address - Fax:732-917-2901
Practice Address - Street 1:10 STERLING DR
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-4911
Practice Address - Country:US
Practice Address - Phone:732-917-2900
Practice Address - Fax:732-917-2901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS NJ HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0600458Medicaid
NJ1821532946OtherNPI FOR SNF