Healthcare Provider Details

I. General information

NPI: 1912101445
Provider Name (Legal Business Name): INTERGRATIVE RECOVERY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PASSAIC ST
HACKENSACK NJ
07601-3525
US

IV. Provider business mailing address

200 PASSAIC ST
HACKENSACK NJ
07601-3525
US

V. Phone/Fax

Practice location:
  • Phone: 201-678-1999
  • Fax: 201-441-3529
Mailing address:
  • Phone: 201-678-1999
  • Fax: 201-441-3529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0031593
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: MR. EMIL IFTODE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 201-678-1999