Provider Demographics
NPI:1336283027
Name:2ND HOME ELIZABETH LLC
Entity Type:Organization
Organization Name:2ND HOME ELIZABETH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-278-7065
Mailing Address - Street 1:100 HAMILTON PLZ
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505-2109
Mailing Address - Country:US
Mailing Address - Phone:973-278-7065
Mailing Address - Fax:973-278-4773
Practice Address - Street 1:432 N BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3365
Practice Address - Country:US
Practice Address - Phone:908-436-0018
Practice Address - Fax:973-278-4773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ908111313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7667027Medicaid