Provider Demographics
NPI:1063627545
Name:SECOND HOME PERTH AMBOY LLC
Entity type:Organization
Organization Name:SECOND HOME PERTH AMBOY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBROAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MINASSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-279-2323
Mailing Address - Street 1:100 HAMILTON PLZ
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505-2109
Mailing Address - Country:US
Mailing Address - Phone:973-279-2323
Mailing Address - Fax:973-278-6284
Practice Address - Street 1:420 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3835
Practice Address - Country:US
Practice Address - Phone:732-826-8012
Practice Address - Fax:732-826-1961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJZ0SFLR311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7667043Medicaid