1386298610 NPI number — THE OPEN DOOR OF NEW JERSEY

Table of content: (NPI 1386298610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386298610 NPI number — THE OPEN DOOR OF NEW JERSEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE OPEN DOOR OF NEW JERSEY
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:
1386298610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1658 LAKEWOOD RD STE 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOMS RIVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08755-1280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-408-5681
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 CHAMBERS BRIDGE RD APT 141
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08723-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-408-5681
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF SERVICES
Authorized Official Telephone Number:
732-408-5681

Provider Taxonomy Codes

  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0477389 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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