MEDICARE: SPECIAL HOMES OF NEW JERSEY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility		NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295252310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECIAL HOMES OF NEW JERSEY, INC.

Provider Business Mailing Address
First Line	:	74 VILLAGE GREEN
Second Line	:	BUILDING 4 APARTMENT L
City	:	BUDD LAKE
State	:	NJ
Zip	:	07828-1379
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	74 VILLAGE GRN APT L
Second Line	:
City	:	BUDD LAKE
State	:	NJ
Zip	:	07828-1379
Country	:	US
Telephone Number	:	973-886-1953
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TERRENCE MCKEON
Credential	:
Telephone Number	:	973-886-1953

Provider Enumeration Date	:	08/29/2017
Last Update Date	:	06/16/2018

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