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General NPI Number Information
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NPI Number | 1205957917
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Entity Type | Organization
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Legal Business Name | MCG BH PACT PROGRAM
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 269 OLIVER ST
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City | NEWARK
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State | NJ
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Zip | 07105-2507
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Country | US
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Telephone | 973-466-1351
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Fax |
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Provider Business Mailing Address
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Address Line | 1 CARPENTER RD
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City | PISCATAWAY
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State | NJ
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Zip | 08854-5280
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Country | US
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Telephone | 732-650-1401
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Fax |
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Authorized Official
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Title or Position | RN
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Name | CHARITY O EZEALA
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Credential |
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Telephone | 973-466-1351
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 26NR09838600
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License Number State | NJ
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