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General NPI Number Information
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NPI Number | 1811359060
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Entity Type | Organization
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Legal Business Name | FOUR WALLS THE 4WALLS LLC
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Dates
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Enumeration Date | 03/27/2016
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Last Update Date | 03/27/2016
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Provider Practice Location Address
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Address Line | 2511 HAMILTON DR
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City | VOORHEES
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State | NJ
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Zip | 08043-2642
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Country | US
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Telephone | 856-650-6556
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 201
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City | SOMERDALE
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State | NJ
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Zip | 08083-0201
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Country | US
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Telephone | 856-650-6556
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. JASON ALI BRICE SR.
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Credential | M.ED
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Telephone | 856-650-6556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0400647708
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License Number State | NJ
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