Provider Demographics
NPI:1730142423
Name:LINCOLN PARK RENAISSANCE REHAB. & NURSING CENTER LLC
Entity Type:Organization
Organization Name:LINCOLN PARK RENAISSANCE REHAB. & NURSING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:FELICIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-696-3300
Mailing Address - Street 1:499 PINE BROOK RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1804
Mailing Address - Country:US
Mailing Address - Phone:973-696-3300
Mailing Address - Fax:973-633-8747
Practice Address - Street 1:499 PINE BROOK RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1804
Practice Address - Country:US
Practice Address - Phone:973-696-3300
Practice Address - Fax:973-633-8747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ061408314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01216893Medicaid
NJ4491904Medicaid
315042Medicare ID - Type Unspecified
NJ4491904Medicaid