Provider Demographics
NPI:1730466392
Name:LAUREL HEALTHCARE LLC
Entity type:Organization
Organization Name:LAUREL HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LLC MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOSHE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-379-8074
Mailing Address - Street 1:24 WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07014-1228
Mailing Address - Country:US
Mailing Address - Phone:917-379-8074
Mailing Address - Fax:
Practice Address - Street 1:18 W LAUREL RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1718
Practice Address - Country:US
Practice Address - Phone:856-784-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060405314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0280917Medicaid
NJ0280917Medicaid