=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003030495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHALLENGE PROGRAM OF NEW JERSEY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 08/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 MARKET ST SUITE 200
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07505-1724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-345-9100
-----------------------------------------------------
Fax | 973-345-9110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 COLT ST SUITE 400
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07505-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-345-9100
-----------------------------------------------------
Fax | 973-345-9110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | MR. WILLIAM THOMPSON
-----------------------------------------------------
Credential | C.A.S.A.C.
-----------------------------------------------------
Telephone | 973-345-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 22583
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------