Provider Demographics
NPI:1407511967
Name:EASTERN CHRISTIAN CHILDREN'S RETREAT
Entity Type:Organization
Organization Name:EASTERN CHRISTIAN CHILDREN'S RETREAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUPICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-848-8005
Mailing Address - Street 1:700 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1099
Mailing Address - Country:US
Mailing Address - Phone:201-848-8005
Mailing Address - Fax:
Practice Address - Street 1:286 NEWTOWN RD
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-2606
Practice Address - Country:US
Practice Address - Phone:201-848-8005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJA9109288Medicaid