Provider Demographics
NPI:1225077290
Name:STATE OF NEW JERSEY OMB CENTRALIZED PAYROLL
Entity Type:Organization
Organization Name:STATE OF NEW JERSEY OMB CENTRALIZED PAYROLL
Other - Org Name:GREEN BROOK DEVELOPMENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ACTING CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BRINDISI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-968-5566
Mailing Address - Street 1:275 GREENBROOK RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08812-2223
Mailing Address - Country:US
Mailing Address - Phone:732-968-6000
Mailing Address - Fax:732-968-0373
Practice Address - Street 1:275 GREENBROOK RD
Practice Address - Street 2:
Practice Address - City:GREEN BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08812-2223
Practice Address - Country:US
Practice Address - Phone:732-968-6000
Practice Address - Fax:732-968-0373
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW JERSEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-05
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31-G009320600000X
NJ25MA04607800320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4503309Medicaid
528587OtherMEDICARE BILLING GROUP NU
NJ4503309Medicaid