Provider Demographics
NPI:1851348627
Name:BURNT TAVERN REHABILITATION AND HEALTH CARE CTR
Entity Type:Organization
Organization Name:BURNT TAVERN REHABILITATION AND HEALTH CARE CTR
Other - Org Name:BURNT TAVERN CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KREIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-840-3700
Mailing Address - Street 1:1049 BURNT TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-1967
Mailing Address - Country:US
Mailing Address - Phone:732-840-3700
Mailing Address - Fax:832-840-0572
Practice Address - Street 1:1049 BURNT TAVERN RD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-1967
Practice Address - Country:US
Practice Address - Phone:732-840-3700
Practice Address - Fax:832-840-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJZBBGDW310400000X
NJ061518314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4494610Medicaid
NJ4494628Medicaid
NJ4494601Medicaid
NJ315213Medicare Oscar/Certification