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General NPI Number Information
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NPI Number | 1831686443
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Entity Type | Organization
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Legal Business Name | GRANDULAR SENIOR LIVING
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Dates
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Enumeration Date | 04/18/2018
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Last Update Date | 04/18/2018
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Provider Practice Location Address
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Address Line | 542 BERLIN CROSS KEY ROAD STE 3-270
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City | SICKLERVILLE
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State | NJ
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Zip | 08081
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Country | US
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Telephone | 856-875-9608
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Fax |
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Provider Business Mailing Address
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Address Line | 542 BERLIN CROSS KEY ROAD STE 3-270
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City | SICKLERVILLE
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State | NJ
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Zip | 08081
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Country | US
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Telephone | 856-875-9608
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. DEBORAH DICKERSON
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Credential | ED.S
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Telephone | 856-875-9605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number | 0450254579
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License Number State | NJ
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