# COUNTY OF GLOUCESTER

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Shady Lane Nursing Home
- **Organization subpart:** No

## Provider details

- **NPI number:** 1447384680
- **Authorized official:** MR. PETE SCAFFIDI (ACCOUNTANT)
- **Authorized official phone:** (856) 423-5318

## Contact information

- **Practice address:** 256 COUNTY HOUSE RD, CLARKSBORO, NJ 08020-1395
- **Practice address phone:** (856) 423-5318
- **Practice address fax:** (856) 423-3634
- **Mailing address:** 254 COUNTY HOUSE RD, CLARKSBORO, NJ 08020-1395
- **Mailing address phone:** (856) 423-5318
- **Mailing address fax:** (856) 423-3634

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 060805 | NJ | Yes |

## Other

- **Enumeration date:** 03/16/2007
- **Last updated:** 06/24/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 4478703 | — | NJ |