Provider Demographics
NPI:1629512181
Name:LEISURE CHATEAU REHAB HUNTINGTONS DISEASE
Entity Type:Organization
Organization Name:LEISURE CHATEAU REHAB HUNTINGTONS DISEASE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:FALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-370-8600
Mailing Address - Street 1:962 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:962 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5605
Practice Address - Country:US
Practice Address - Phone:732-370-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEISURE CHATEAU ACQUISITION LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ061515314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0516082Medicaid