Healthcare Provider Details

I. General information

NPI: 1437386596
Provider Name (Legal Business Name): CENTER FOR INDEPENDENT LIVING OF SOUTH JERSEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 DELSEA DR SUITE 1,
WESTVILLE NJ
08093-2225
US

IV. Provider business mailing address

1150 DELSEA DR SUITE 1,
WESTVILLE NJ
08093-2225
US

V. Phone/Fax

Practice location:
  • Phone: 856-853-6490
  • Fax: 856-853-1466
Mailing address:
  • Phone: 856-853-6490
  • Fax: 856-853-1466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number251B00000X
License Number StateNJ

VIII. Authorized Official

Name: MRS. HAZEL L LEE-BRIGGSD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 856-853-6490