Healthcare Provider Details

I. General information

NPI: 1639318306
Provider Name (Legal Business Name): SPECTRUM FOR LIVING DEVELOPMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BLANCH AVE
CLOSTER NJ
07624-1228
US

IV. Provider business mailing address

210 RIVERVALE RD
RIVERVALE NJ
07675-6281
US

V. Phone/Fax

Practice location:
  • Phone: 201-784-9400
  • Fax:
Mailing address:
  • Phone: 201-358-8000
  • Fax: 201-358-8089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number83011
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number31G012
License Number StateNJ

VIII. Authorized Official

Name: MR. CARMINE G MARCHIONDA
Title or Position: PRESIDENT/CEO
Credential: LNHA, MBA, MPHA
Phone: 201-358-8086