Provider Demographics
NPI:1386770410
Name:SYCAMORE MANOR LLC
Entity type:Organization
Organization Name:SYCAMORE MANOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-784-2400
Mailing Address - Street 1:864 SHREWSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724
Mailing Address - Country:US
Mailing Address - Phone:732-784-2400
Mailing Address - Fax:732-542-6447
Practice Address - Street 1:864 SHREWSBURY AVE
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724
Practice Address - Country:US
Practice Address - Phone:732-784-2400
Practice Address - Fax:732-542-6447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQ4VDWW310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8767017Medicaid