Provider Demographics
NPI:1093890378
Name:PEDIATRIC DAY HLTH CRT @ MILLH
Entity Type:Organization
Organization Name:PEDIATRIC DAY HLTH CRT @ MILLH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-663-4044
Mailing Address - Street 1:1114 WYNNWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-3256
Mailing Address - Country:US
Mailing Address - Phone:856-663-4044
Mailing Address - Fax:856-663-3444
Practice Address - Street 1:325 JERSEY ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08611-3113
Practice Address - Country:US
Practice Address - Phone:609-396-2299
Practice Address - Fax:609-396-7611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0061212Medicaid