Healthcare Provider Details

I. General information

NPI: 1255375929
Provider Name (Legal Business Name): STATE OF NEW JERSEY OMB CENTRALIZED PAYROLL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RTE 72 EAST
NEW LISBON NJ
08064-0130
US

IV. Provider business mailing address

HWY 72 EAST
NEW LISBON NJ
08064-0130
US

V. Phone/Fax

Practice location:
  • Phone: 609-894-4001
  • Fax: 609-726-1293
Mailing address:
  • Phone: 609-894-4001
  • Fax: 609-726-1293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number4467001
License Number StateNJ

VIII. Authorized Official

Name: MRS. JANENE M HAWK
Title or Position: ASSISTANT BUSINESS MANAGER
Credential: MASTERS IN MGMT
Phone: 609-894-4001