MEDICARE: EASTER SEALS 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	320800000X	Mental Illness Community Based Residential Treatment Facility	40003-M40-00-41	NJ

General Provider Information

NPI Number	:	1952667644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS OF NEW JERSEY INC

Provider Business Mailing Address
First Line	:	25 KENNEDY BLVD STE 600
Second Line	:
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-1262
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 KENNEDY BLVD STE 600
Second Line	:
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-1262
Country	:	US
Telephone Number	:	732-257-6662
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN FITZGERALD
Credential	:
Telephone Number	:	732-257-6662

Provider Enumeration Date	:	04/06/2012
Last Update Date	:	04/06/2012

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