Provider Demographics
NPI:1740325877
Name:PARAGON VILLAGE, LLC.
Entity type:Organization
Organization Name:PARAGON VILLAGE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DRIECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:POLACHEK
Authorized Official - Suffix:
Authorized Official - Credentials:CALA
Authorized Official - Phone:908-498-0102
Mailing Address - Street 1:427 US HIGHWAY 46 E
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-2683
Mailing Address - Country:US
Mailing Address - Phone:908-498-0107
Mailing Address - Fax:
Practice Address - Street 1:427 US HIGHWAY 46 E
Practice Address - Street 2:
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-2683
Practice Address - Country:US
Practice Address - Phone:908-498-0107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ60A008310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNJ60A008OtherALR
NJ0029688Medicaid