Provider Demographics
NPI:1437605656
Name:JOHN BROOKS RECOVERY CENTER, A NEW JERSEY NON-PROFIT CORPORATION
Entity Type:Organization
Organization Name:JOHN BROOKS RECOVERY CENTER, A NEW JERSEY NON-PROFIT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-345-2020
Mailing Address - Street 1:660 BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232
Mailing Address - Country:US
Mailing Address - Phone:609-345-2020
Mailing Address - Fax:609-646-7027
Practice Address - Street 1:1931 BACHARACH BLVD
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401
Practice Address - Country:US
Practice Address - Phone:609-345-2020
Practice Address - Fax:609-646-7027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000466261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0101702Medicaid
NJ0101702Medicaid
NJ7620608Medicaid