Provider Demographics
NPI:1407998842
Name:SPECTRUM FOR LIVING DEVELOPMENT, INC.
Entity Type:Organization
Organization Name:SPECTRUM FOR LIVING DEVELOPMENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:MUILENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-358-8000
Mailing Address - Street 1:210 RIVERVALE ROAD, SUITE 3
Mailing Address - Street 2:
Mailing Address - City:RIVER VALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675
Mailing Address - Country:US
Mailing Address - Phone:201-358-8000
Mailing Address - Fax:201-358-8089
Practice Address - Street 1:210 RIVERVALE ROAD, SUITE 3
Practice Address - Street 2:
Practice Address - City:RIVER VALE
Practice Address - State:NJ
Practice Address - Zip Code:07675
Practice Address - Country:US
Practice Address - Phone:201-358-8000
Practice Address - Fax:201-358-8089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ83011251C00000X
385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6961703Medicaid