1912258146 NPI number — LIFETIES, INC TRIAD SPECIAL NEEDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912258146 NPI number — LIFETIES, INC TRIAD SPECIAL NEEDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIES, INC TRIAD SPECIAL NEEDS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912258146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2205 PENNINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EWING
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08638-1212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2205 PENNINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EWING
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08638-1212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-771-1600
Provider Business Practice Location Address Fax Number:
609-530-1648
Provider Enumeration Date:
09/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
INZANA
Authorized Official First Name:
MARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
C.E.O./FOUNDER
Authorized Official Telephone Number:
609-771-1600

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0297933 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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