Healthcare Provider Details

I. General information

NPI: 1205346574
Provider Name (Legal Business Name): MARYVILLE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1173 E LANDIS AVE
VINELAND NJ
08360
US

IV. Provider business mailing address

129 JOHNSON RD STE 7
TURNERSVILLE NJ
08012-1777
US

V. Phone/Fax

Practice location:
  • Phone: 856-690-1000
  • Fax: 856-690-1764
Mailing address:
  • Phone: 856-863-3913
  • Fax: 856-863-3917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number2000300
License Number StateNJ

VIII. Authorized Official

Name: JARED LEVY
Title or Position: CFO
Credential:
Phone: 856-863-3913