Provider Demographics
NPI:1942224423
Name:HOSPICE OF NEW JERSEY, LLC
Entity Type:Organization
Organization Name:HOSPICE OF NEW JERSEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICH
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-493-6745
Mailing Address - Street 1:50 N LAURA ST
Mailing Address - Street 2:STE 1800
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-3664
Mailing Address - Country:US
Mailing Address - Phone:904-493-6745
Mailing Address - Fax:904-262-4804
Practice Address - Street 1:400 BROADACRES DR
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3156
Practice Address - Country:US
Practice Address - Phone:973-893-0818
Practice Address - Fax:973-893-9828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6506909Medicaid
NJ311540Medicare ID - Type UnspecifiedNJ MEDICARE