=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750758058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YODEL MENTAL HEALTH & DEVELOPMENTAL DISABILITIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2015
-----------------------------------------------------
Last Update Date | 08/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 SUNSET RD
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08016-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-747-8007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 E STOKES RD
-----------------------------------------------------
City | WILLINGBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08046-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-424-4856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC. DIR
-----------------------------------------------------
Name | MR. AYODELE JOSEPH OMOMO
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 609-424-4856
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------