Healthcare Provider Details

I. General information

NPI: 1659898880
Provider Name (Legal Business Name): SPECIAL HOMES OF NEW JERSEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CENTRAL AVE
HACKENSACK NJ
07601-3439
US

IV. Provider business mailing address

202 CENTRAL AVE
HACKENSACK NJ
07601-3439
US

V. Phone/Fax

Practice location:
  • Phone: 973-886-1953
  • Fax:
Mailing address:
  • Phone: 973-886-1953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier1639500796
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: TERRENCE MCKEON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 973-886-1953