=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720797574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDEN STATE TREATMENT CENTER BH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2022
-----------------------------------------------------
Last Update Date | 01/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 SPARTA AVE STE A201
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07871-1120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-818-9901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7050 W PALMETTO PARK ROAD SUITE 15 #181
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-818-9901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING DIRECTOR
-----------------------------------------------------
Name | KARA QUINN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-818-9901
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------