Healthcare Provider Details

I. General information

NPI: 1144845595
Provider Name (Legal Business Name): AMATEUR ATHLETIC UNION OF THE UNITED STATES / SPECIAL DRAGONS A NJ NON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

242 CHESTNUT ST
NUTLEY NJ
07110-2329
US

IV. Provider business mailing address

77 TIONA AVE
BELLEVILLE NJ
07109-2235
US

V. Phone/Fax

Practice location:
  • Phone: 973-667-8525
  • Fax:
Mailing address:
  • Phone: 973-667-8525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE BOSTORY
Title or Position: FOUNDER
Credential: MAT
Phone: 973-667-8525