1861876419 NPI number — FAIRLAWN BEHAVIORAL ASSOCIATES LLC

Table of content: (NPI 1861876419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861876419 NPI number — FAIRLAWN BEHAVIORAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRLAWN BEHAVIORAL ASSOCIATES LLC
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:
1861876419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 809
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEANECK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07666-0809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-342-4004
Provider Business Mailing Address Fax Number:
201-243-7874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15-01 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE# 10B
Provider Business Practice Location Address City Name:
FAIR LAWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07410-6003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-342-4004
Provider Business Practice Location Address Fax Number:
201-342-4008
Provider Enumeration Date:
07/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JAN
Authorized Official First Name:
MOHSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTARTOR
Authorized Official Telephone Number:
201-289-8455

Provider Taxonomy Codes

  • Taxonomy code: 103TP0016X , with the licence number:  25MA6506500 , 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: 7492201 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com