Healthcare Provider Details

I. General information

NPI: 1053860130
Provider Name (Legal Business Name): JOHN BROOKS RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 BLACK HORSE PIKE
PLEASANTVILLE NJ
08232
US

IV. Provider business mailing address

660 BLACK HORSE PIKE
PLEASANTVILLE NJ
08232
US

V. Phone/Fax

Practice location:
  • Phone: 609-345-2020
  • Fax: 609-646-7027
Mailing address:
  • Phone: 609-345-2020
  • Fax: 609-646-7027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number2000275
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number2000079
License Number StateNJ

VIII. Authorized Official

Name: SHARON ZIMMER
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 609-345-2020