Provider Demographics
NPI:1780858191
Name:NURSE PRACTITIONERS IN LONG TERM CARE LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:NURSE PRACTITIONERS IN LONG TERM CARE LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:973-843-2099
Mailing Address - Street 1:1992 MORRIS AVE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-3507
Mailing Address - Country:US
Mailing Address - Phone:973-843-2099
Mailing Address - Fax:
Practice Address - Street 1:1992 MORRIS AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-3507
Practice Address - Country:US
Practice Address - Phone:973-843-2099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR07760600363L00000X
NJ332171363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ054243Medicare PIN
NJ095299Medicare PIN