Provider Demographics
NPI:1942425897
Name:ASSISTED LIVING OF WALL TOWNSHIP, LLC
Entity type:Organization
Organization Name:ASSISTED LIVING OF WALL TOWNSHIP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:RENEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:NJCALA
Authorized Official - Phone:732-282-1014
Mailing Address - Street 1:2018 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07762-2558
Mailing Address - Country:US
Mailing Address - Phone:732-282-1014
Mailing Address - Fax:732-282-1050
Practice Address - Street 1:2018 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07762-2558
Practice Address - Country:US
Practice Address - Phone:732-282-1014
Practice Address - Fax:732-282-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1EGWIO310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8608806Medicaid