1275084576 NPI number — SPECTRUM 360 A NEW JERSEY NONPROFIT CORPORATION

Table of content: (NPI 1275084576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275084576 NPI number — SPECTRUM 360 A NEW JERSEY NONPROFIT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM 360 A NEW JERSEY NONPROFIT CORPORATION
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:
1275084576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 EAGLE ROCK AVE
Provider Second Line Business Mailing Address:
SUITE 200 B
Provider Business Mailing Address City Name:
WEST ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07052-4229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-509-3050
Provider Business Mailing Address Fax Number:
973-509-0185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 S JEFFERSON RD
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
WHIPPANY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07981-1067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-509-3050
Provider Business Practice Location Address Fax Number:
973-509-0185
Provider Enumeration Date:
10/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ETTINGER
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
973-509-3050

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  221500528A , 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: 0496138 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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