Provider Demographics
NPI:1699815712
Name:COLTS NECK VILLAGE
Entity Type:Organization
Organization Name:COLTS NECK VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR LTC ACCOUNTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-206-8003
Mailing Address - Street 1:3 MERIDIAN WAY
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-2419
Mailing Address - Country:US
Mailing Address - Phone:732-303-3100
Mailing Address - Fax:
Practice Address - Street 1:3 MERIDIAN WAY
Practice Address - Street 2:
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-2419
Practice Address - Country:US
Practice Address - Phone:732-303-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ7EKKEK310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8748306Medicaid