1366979494 NPI number — RECOVERY CENTERS OF AMERICA AT MANAHAWKIN NJ MEDICAID ONLY

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 1366979494 NPI number — RECOVERY CENTERS OF AMERICA AT MANAHAWKIN NJ MEDICAID ONLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RECOVERY CENTERS OF AMERICA AT MANAHAWKIN NJ MEDICAID ONLY
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:
1366979494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/09/2018
NPI Reactivation Date:
02/04/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2201 RENAISSANCE BLVD FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-994-2900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N MAIN ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANAHAWKIN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08050-3730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-994-2900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLURE
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
610-994-2900

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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