Provider Demographics
NPI:1235513961
Name:HOLLYDELL, INC.
Entity Type:Organization
Organization Name:HOLLYDELL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACANNE
Authorized Official - Middle Name:H
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-582-5151
Mailing Address - Street 1:610 HOLLY DELL DR
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-9120
Mailing Address - Country:US
Mailing Address - Phone:856-582-5151
Mailing Address - Fax:856-582-5055
Practice Address - Street 1:328B NORTH BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08071
Practice Address - Country:US
Practice Address - Phone:856-678-2160
Practice Address - Fax:856-678-2162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2160Medicaid