Provider Demographics
NPI:1932108693
Name:11 HISTORY LANE OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:11 HISTORY LANE OPERATING COMPANY, LLC
Other - Org Name:CARE ONE AT JACKSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP & GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:A.
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-242-4000
Mailing Address - Street 1:11 HISTORY LANE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527
Mailing Address - Country:US
Mailing Address - Phone:732-367-6600
Mailing Address - Fax:732-905-9641
Practice Address - Street 1:11 HISTORY LANE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527
Practice Address - Country:US
Practice Address - Phone:732-367-6600
Practice Address - Fax:732-905-9641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ314000000X
NJ0088447385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0059994Medicaid
NJ315240Medicare Oscar/Certification