=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356454615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERV CENTERS OF NEW JERSEY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 04/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 BLOOMFIELD AVE STE B SUITE B
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07012-1242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-594-0125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 SCOTCH RD
-----------------------------------------------------
City | EWING
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08628-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-406-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. JAMES J ROSE
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 609-406-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 500049704
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------