Provider Demographics
NPI:1235453689
Name:LEADING EDGE RECOVERY CENTER
Entity Type:Organization
Organization Name:LEADING EDGE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BEVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-537-5372
Mailing Address - Street 1:1777 KLOCKNER RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-2725
Mailing Address - Country:US
Mailing Address - Phone:561-577-3174
Mailing Address - Fax:
Practice Address - Street 1:1777 KLOCKNER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-2725
Practice Address - Country:US
Practice Address - Phone:561-577-3174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000340-10324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility