Healthcare Provider Details

I. General information

NPI: 1710671979
Provider Name (Legal Business Name): THE CLUB OF BERGEN COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22-08 ROUTE 208 STE 8
FAIR LAWN NJ
07410-2609
US

IV. Provider business mailing address

22-08 ROUTE 208 STE 8
FAIR LAWN NJ
07410-2609
US

V. Phone/Fax

Practice location:
  • Phone: 201-773-9090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: DAVID GENDY
Title or Position: MANAGER
Credential: RN
Phone: 201-234-9105