Provider Demographics
NPI:1174669626
Name:THERACARE OF NEW JERSEY LLC
Entity Type:Organization
Organization Name:THERACARE OF NEW JERSEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-564-2350
Mailing Address - Street 1:67 WALNUT AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1640
Mailing Address - Country:US
Mailing Address - Phone:888-311-2611
Mailing Address - Fax:
Practice Address - Street 1:67 WALNUT AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1640
Practice Address - Country:US
Practice Address - Phone:888-311-2611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0038679Medicaid