Provider Demographics
NPI:1619699394
Name:30 PRINCETON OPCO LLC
Entity Type:Organization
Organization Name:30 PRINCETON OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:ELIYAHU
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-796-6175
Mailing Address - Street 1:30 PRINCETON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-2405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 PRINCETON BLVD
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-2405
Practice Address - Country:US
Practice Address - Phone:978-454-8086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility