Healthcare Provider Details

I. General information

NPI: 1407998842
Provider Name (Legal Business Name): SPECTRUM FOR LIVING DEVELOPMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 RIVERVALE ROAD, SUITE 3
RIVER VALE NJ
07675
US

IV. Provider business mailing address

210 RIVERVALE ROAD, SUITE 3
RIVER VALE NJ
07675
US

V. Phone/Fax

Practice location:
  • Phone: 201-358-8000
  • Fax: 201-358-8089
Mailing address:
  • Phone: 201-358-8000
  • Fax: 201-358-8089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number83011
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM G. MUILENBURG
Title or Position: CFO
Credential:
Phone: 201-358-8000