Provider Demographics
NPI:1336486547
Name:PUERTO RICAN ORG FOR COMMUNITY EDUCATIONAL & ECONOMIC DEVELOPMENT
Entity Type:Organization
Organization Name:PUERTO RICAN ORG FOR COMMUNITY EDUCATIONAL & ECONOMIC DEVELOPMENT
Other - Org Name:PROCEED INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTO VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-351-7664
Mailing Address - Street 1:1126 DICKINSON ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2404
Mailing Address - Country:US
Mailing Address - Phone:908-351-7664
Mailing Address - Fax:908-353-5460
Practice Address - Street 1:1122 E. GRAND ST.
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201
Practice Address - Country:US
Practice Address - Phone:908-351-7727
Practice Address - Fax:908-353-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000311251S00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0340073Medicaid
NJ0340073Medicaid