Provider Demographics
NPI:1205390622
Name:MERCHANTVILLE ADDICTION TREATMENT LLC
Entity Type:Organization
Organization Name:MERCHANTVILLE ADDICTION TREATMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-449-6159
Mailing Address - Street 1:1 S CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:MERCHANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-2213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 S CENTRE ST
Practice Address - Street 2:
Practice Address - City:MERCHANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08109-2213
Practice Address - Country:US
Practice Address - Phone:800-663-5548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility