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General NPI Number Information
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NPI Number | 1205058567
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Entity Type | Organization
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Legal Business Name | MARYVILLE, INC.
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 04/07/2010
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Provider Practice Location Address
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Address Line | 567 SALEM-QUINTON RD
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City | SALEM
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State | NJ
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Zip | 08079
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Country | US
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Telephone | 856-935-9305
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Fax | 856-935-9269
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Provider Business Mailing Address
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Address Line | 567 SALEM-QUINTON RD
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City | SALEM
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State | NJ
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Zip | 08079
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Country | US
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Telephone | 856-935-9305
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Fax | 856-935-9269
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Authorized Official
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Title or Position | CEO
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Name | MR. JAMES O'BRIEN
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Credential | MSW, LCADC
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Telephone | 256-227-2717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 23016
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License Number State | NJ
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