Provider Demographics
NPI:1063676724
Name:JOHN BROOKS RECOVERY CENTER
Entity Type:Organization
Organization Name:JOHN BROOKS RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDESSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-347-8615
Mailing Address - Street 1:1315 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-7204
Mailing Address - Country:US
Mailing Address - Phone:609-347-8615
Mailing Address - Fax:
Practice Address - Street 1:1315 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-7204
Practice Address - Country:US
Practice Address - Phone:609-347-8615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ80160324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7620608Medicaid