Provider Demographics
NPI:1437462504
Name:EBONY ISLAND SHELTER COMPANY
Entity Type:Organization
Organization Name:EBONY ISLAND SHELTER COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-262-7396
Mailing Address - Street 1:127 EASTMONT LN
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1913
Mailing Address - Country:US
Mailing Address - Phone:856-262-7396
Mailing Address - Fax:856-262-8691
Practice Address - Street 1:127 EASTMONT LN
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-1913
Practice Address - Country:US
Practice Address - Phone:856-262-7396
Practice Address - Fax:856-262-8691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJV58475691600320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities