Provider Demographics
NPI:1699846113
Name:KENNEDY HEALTH SYSTEM ASSISTED LIVING
Entity Type:Organization
Organization Name:KENNEDY HEALTH SYSTEM ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP AMBULATORY SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-566-5279
Mailing Address - Street 1:1099 WHITE HORSE RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4405
Mailing Address - Country:US
Mailing Address - Phone:856-566-2092
Mailing Address - Fax:856-566-5288
Practice Address - Street 1:.3501 WEST CHAPEL AVENUE
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08022
Practice Address - Country:US
Practice Address - Phone:856-667-6826
Practice Address - Fax:856-667-6907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ15A111310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8344906Medicaid