Provider Demographics
NPI:1457593444
Name:TAG SENIOR CARE LLC
Entity Type:Organization
Organization Name:TAG SENIOR CARE LLC
Other - Org Name:CLOVER REST HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-841-5483
Mailing Address - Street 1:28 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07832-2324
Mailing Address - Country:US
Mailing Address - Phone:908-496-4307
Mailing Address - Fax:
Practice Address - Street 1:28 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:NJ
Practice Address - Zip Code:07832-2324
Practice Address - Country:US
Practice Address - Phone:908-496-4307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ62104314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility