Healthcare Provider Details

I. General information

NPI: 1710400106
Provider Name (Legal Business Name): UNICORN SUPPORTIVE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 VALLEY FORGE DR
SWEDESBORO NJ
08085-4230
US

IV. Provider business mailing address

22 VALLEY FORGE DR
SWEDESBORO NJ
08085-4230
US

V. Phone/Fax

Practice location:
  • Phone: 856-278-5188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNJ

VIII. Authorized Official

Name: MONDAY J GABRIEL
Title or Position: ADMINISTRATOR
Credential:
Phone: 856-278-5188