Provider Demographics
NPI:1184889818
Name:CHESTNUT HILL RESIDENCE
Entity type:Organization
Organization Name:CHESTNUT HILL RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:S
Authorized Official - Last Name:REQUEJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-777-7800
Mailing Address - Street 1:338 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-3158
Mailing Address - Country:US
Mailing Address - Phone:973-777-7800
Mailing Address - Fax:973-778-9013
Practice Address - Street 1:338 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-3158
Practice Address - Country:US
Practice Address - Phone:973-777-7800
Practice Address - Fax:973-778-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ16A001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility