Provider Demographics
NPI:1912276882
Name:STRATFORD MANOR REHABILITATION AND CARE CENTER LLC
Entity Type:Organization
Organization Name:STRATFORD MANOR REHABILITATION AND CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LLC MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRKHANI
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA, MBA
Authorized Official - Phone:201-232-3905
Mailing Address - Street 1:787 NORTHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1131
Mailing Address - Country:US
Mailing Address - Phone:201-232-3905
Mailing Address - Fax:201-489-6021
Practice Address - Street 1:787 NORTHFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1131
Practice Address - Country:US
Practice Address - Phone:973-731-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060714314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0293539Medicaid
NJ315066Medicare Oscar/Certification