Provider Demographics
NPI:1659421162
Name:ASSISTED LIVING OF FORKED RIVER, INC.
Entity Type:Organization
Organization Name:ASSISTED LIVING OF FORKED RIVER, INC.
Other - Org Name:SPRING OAK ASSISTED LIVING OF FORKED RIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGEMENT AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:RADER
Authorized Official - Suffix:
Authorized Official - Credentials:RN,CALA
Authorized Official - Phone:908-859-8500
Mailing Address - Street 1:1503 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-3736
Mailing Address - Country:US
Mailing Address - Phone:908-859-8500
Mailing Address - Fax:908-859-5151
Practice Address - Street 1:1503 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-3736
Practice Address - Country:US
Practice Address - Phone:908-859-8500
Practice Address - Fax:908-859-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ65A006310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8131309Medicaid