Provider Demographics
NPI:1437530573
Name:DUNGARVIN NEW JERSEY, LLC-SOMERSET DAY PROGRAM ATID
Entity Type:Organization
Organization Name:DUNGARVIN NEW JERSEY, LLC-SOMERSET DAY PROGRAM ATID
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-789-5905
Mailing Address - Street 1:1543 STATE ROUTE 27
Mailing Address - Street 2:SUITE 24
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-4015
Mailing Address - Country:US
Mailing Address - Phone:732-463-7227
Mailing Address - Fax:
Practice Address - Street 1:1543 STATE ROUTE 27
Practice Address - Street 2:SUITE 16
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873
Practice Address - Country:US
Practice Address - Phone:732-627-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUNGARVIN GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-15
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0494275Medicaid