Provider Demographics
NPI:1649206327
Name:3809 BAYSHORE ROAD OPERATIONS LLC
Entity Type:Organization
Organization Name:3809 BAYSHORE ROAD OPERATIONS LLC
Other - Org Name:VICTORIA MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:KIELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:610-925-4436
Mailing Address - Fax:610-925-4351
Practice Address - Street 1:3809 BAYSHORE RD
Practice Address - Street 2:
Practice Address - City:NORTH CAPE MAY
Practice Address - State:NJ
Practice Address - Zip Code:08204-3259
Practice Address - Country:US
Practice Address - Phone:609-898-0677
Practice Address - Fax:609-898-1186
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS NJ HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-24
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060508314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
316929OtherUS FAMILY HEALTH PLAN
62-1518645OtherCONSUMER HEALTH NETWORK
489813OtherAETNA-HMO
4471709OtherUNISYS #
62-1518645OtherAETNA-NONHMO
0006179000OtherAMERIHEALTH
NJ0261173OtherMOLINA #
315281OtherHORIZON - SNF
62-1518645OtherHNFS-TRICARE
62-1518645OtherCIGNA-NJ
000852OtherHORIZON - SUB
NJ05400Medicaid
62-1518645OtherHCPC
62-1518645OtherCONSUMER HEALTH NETWORK