Provider Demographics
NPI:1891206314
Name:LAN DEPTFORD, LLC
Entity Type:Organization
Organization Name:LAN DEPTFORD, LLC
Other - Org Name:FOX TRAIL AT TALL PINES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-364-0155
Mailing Address - Street 1:38 N. CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07466
Mailing Address - Country:US
Mailing Address - Phone:201-368-7070
Mailing Address - Fax:201-368-7060
Practice Address - Street 1:1674 DELSEA DRIVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-4117
Practice Address - Country:US
Practice Address - Phone:856-209-4956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility