Healthcare Provider Details

I. General information

NPI: 1912258146
Provider Name (Legal Business Name): LIFETIES, INC TRIAD SPECIAL NEEDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 PENNINGTON RD
EWING NJ
08638-1212
US

IV. Provider business mailing address

2205 PENNINGTON RD
EWING NJ
08638-1212
US

V. Phone/Fax

Practice location:
  • Phone: 609-771-1600
  • Fax: 609-530-1648
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS MARY M INZANA
Title or Position: C.E.O./FOUNDER
Credential:
Phone: 609-771-1600