MEDICARE: CENTER FOR FAMILY SUPPORT, NEW JERSEY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	GH1227	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447784475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR FAMILY SUPPORT, NEW JERSEY, INC.

Provider Business Mailing Address
First Line	:	333 7TH AVE FL 9
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-5827
Country	:	US
Telephone Number	:	212-629-7939
Fax Number	:	212-239-2211

Provider Business Practice Location Address
First Line	:	1086 CENTRAL AVE
Second Line	:
City	:	PLAINFIELD
State	:	NJ
Zip	:	07060-2811
Country	:	US
Telephone Number	:	908-755-3266
Fax Number	:	908-755-3331

Authorized Official
Title or Position	:	ASSISTANT EXECUTIVE DIRECTOR
Name	:	MICHAEL MAZZOCCO
Credential	:
Telephone Number	:	212-629-7939

Provider Enumeration Date	:	04/17/2017
Last Update Date	:	04/17/2017

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