Provider Demographics
NPI:1619362563
Name:493 BLACK OAK RIDGE ROAD, LLC
Entity Type:Organization
Organization Name:493 BLACK OAK RIDGE ROAD, LLC
Other - Org Name:CARE ONE AT WAYNE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT & G.C.
Authorized Official - Prefix:
Authorized Official - First Name:ANDROSKY
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:201-242-4006
Mailing Address - Street 1:493 BLACK OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-6501
Mailing Address - Country:US
Mailing Address - Phone:973-692-9500
Mailing Address - Fax:
Practice Address - Street 1:493 BLACK OAK RIDGE RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-6501
Practice Address - Country:US
Practice Address - Phone:973-692-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:493 BLACK OAK RIDGE ROAD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJVQXWIZ310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ315477Medicare PIN