Provider Demographics
NPI:1841351541
Name:WANAQUE CONVALESCENT CENTER
Entity type:Organization
Organization Name:WANAQUE CONVALESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-663-4044
Mailing Address - Street 1:1433 RINGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07420-1520
Mailing Address - Country:US
Mailing Address - Phone:973-839-2119
Mailing Address - Fax:973-839-5155
Practice Address - Street 1:1433 RINGWOOD AVE
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:NJ
Practice Address - Zip Code:07420-1520
Practice Address - Country:US
Practice Address - Phone:973-839-2119
Practice Address - Fax:973-839-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0616283140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01057345Medicaid
NJ4496001Medicaid
NY01292924Medicaid