Provider Demographics
NPI:1295122075
Name:BRISTOL GLEN, INC.
Entity type:Organization
Organization Name:BRISTOL GLEN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-922-2980
Mailing Address - Street 1:205 JUMPING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-3197
Mailing Address - Country:US
Mailing Address - Phone:732-922-9800
Mailing Address - Fax:732-922-9804
Practice Address - Street 1:200 BRISTOL GLEN DRIVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860
Practice Address - Country:US
Practice Address - Phone:973-300-5788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ85A001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4504003Medicaid
315439Medicare PIN