1003030495 NPI number — CHALLENGE PROGRAM OF NEW JERSEY INC

Table of content: (NPI 1003030495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003030495 NPI number — CHALLENGE PROGRAM OF NEW JERSEY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHALLENGE PROGRAM OF NEW JERSEY INC
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:
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:
1003030495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 COLT ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
PATERSON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07505-1401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-345-9100
Provider Business Mailing Address Fax Number:
973-345-9110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
152 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PATERSON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07505-1724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-345-9100
Provider Business Practice Location Address Fax Number:
973-345-9110
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
973-345-9100

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  22583 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8102503 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7639309 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7512503 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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