Healthcare Provider Details

I. General information

NPI: 1740705813
Provider Name (Legal Business Name): TO BE DETERMINED A NJ NON PROFIT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 CLIFTON PL APT 306
JERSEY CITY NJ
07304-6150
US

IV. Provider business mailing address

126 CLIFTON PLACE SUITE 306
JERSEY CITY NJ
07304
US

V. Phone/Fax

Practice location:
  • Phone: 551-689-8268
  • Fax:
Mailing address:
  • Phone: 551-689-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TONY HARRINGTON
Title or Position: TRUSTEE
Credential:
Phone: 551-689-8268