Healthcare Provider Details

I. General information

NPI: 1790503068
Provider Name (Legal Business Name): BEACON SPECIALIZED LIVING NEW JERSEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 CURRIER WAY
EWING NJ
08628-1506
US

IV. Provider business mailing address

13 ROSZEL RD STE B110
PRINCETON NJ
08540-6211
US

V. Phone/Fax

Practice location:
  • Phone: 609-987-5003
  • Fax:
Mailing address:
  • Phone: 609-987-5003
  • Fax: 609-520-7979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DARREN HODGDON
Title or Position: PRESIDENT
Credential:
Phone: 269-427-8400