Provider Demographics
NPI:1659411437
Name:FELLOWSHIP SENIOR LIVING, INC.
Entity Type:Organization
Organization Name:FELLOWSHIP SENIOR LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO & EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:GOTH
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:908-580-3805
Mailing Address - Street 1:8000 FELLOWSHIP RD
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-2932
Mailing Address - Country:US
Mailing Address - Phone:908-580-3800
Mailing Address - Fax:908-647-2820
Practice Address - Street 1:9000 FELLOWSHIP RD
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-3912
Practice Address - Country:US
Practice Address - Phone:908-580-3800
Practice Address - Fax:908-647-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ082436310400000X
NJ061425314000000X
NJ035724363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Single Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ315356Medicare Oscar/Certification
NJ035724Medicare PIN