Provider Demographics
NPI:1720096035
Name:HW WEIDCO REN LLC
Entity Type:Organization
Organization Name:HW WEIDCO REN LLC
Other - Org Name:SOUTH JERSEY EXTENDED CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-488-6789
Mailing Address - Street 1:1 UNIVERSITY PLZ
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-6201
Mailing Address - Country:US
Mailing Address - Phone:201-488-6789
Mailing Address - Fax:201-488-7734
Practice Address - Street 1:99 MANHEIM AVE
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2114
Practice Address - Country:US
Practice Address - Phone:856-455-2100
Practice Address - Fax:856-455-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060602314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4473701Medicaid
NJ4473701Medicaid