Provider Demographics
NPI:1023493236
Name:475 JACK MARTIN BOULEVARD OPERATIONS LLC
Entity type:Organization
Organization Name:475 JACK MARTIN BOULEVARD OPERATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:475 JACK MARTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7732
Mailing Address - Country:US
Mailing Address - Phone:732-458-6600
Mailing Address - Fax:732-458-6601
Practice Address - Street 1:475 JACK MARTIN BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7732
Practice Address - Country:US
Practice Address - Phone:732-458-6600
Practice Address - Fax:732-458-6601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS NJ HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-29
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility