Provider Demographics
NPI:1962097600
Name:SJV 1 MADISON OPCO LLC
Entity type:Organization
Organization Name:SJV 1 MADISON OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR REIMBURSEMENT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-854-0830
Mailing Address - Street 1:215 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-1003
Mailing Address - Country:US
Mailing Address - Phone:973-301-0005
Mailing Address - Fax:973-301-0022
Practice Address - Street 1:215 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-1003
Practice Address - Country:US
Practice Address - Phone:973-301-0005
Practice Address - Fax:973-301-0022
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VOLANS SUNRISE JV TRS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-04
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0946516Medicaid