Provider Demographics
NPI:1679964712
Name:SL MILLVILLE, LLC
Entity type:Organization
Organization Name:SL MILLVILLE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA-WORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-825-4002
Mailing Address - Street 1:1719 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-4632
Mailing Address - Country:US
Mailing Address - Phone:856-825-4002
Mailing Address - Fax:856-327-2037
Practice Address - Street 1:1719 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-4632
Practice Address - Country:US
Practice Address - Phone:856-825-4002
Practice Address - Fax:856-327-2037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ90108310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0457761Medicaid