Provider Demographics
NPI:1952319535
Name:MR OF TRENTON LLC
Entity Type:Organization
Organization Name:MR OF TRENTON LLC
Other - Org Name:PROVIDENCE NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FISCHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RISPLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-488-6789
Mailing Address - Street 1:1 UNIVERSITY PLZ
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-6201
Mailing Address - Country:US
Mailing Address - Phone:201-488-6789
Mailing Address - Fax:
Practice Address - Street 1:439 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-4501
Practice Address - Country:US
Practice Address - Phone:609-396-2646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ061101314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4483901Medicaid
NJ4483901Medicaid