Provider Demographics
NPI:1518134360
Name:SOUTH HACKENSACK
Entity Type:Organization
Organization Name:SOUTH HACKENSACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF SCHOOL ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFABIIS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:201-440-2782
Mailing Address - Street 1:1 DYER AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07606-1537
Mailing Address - Country:US
Mailing Address - Phone:201-440-2782
Mailing Address - Fax:201-440-9156
Practice Address - Street 1:1 DYER AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07606-1537
Practice Address - Country:US
Practice Address - Phone:201-440-2782
Practice Address - Fax:201-440-9156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ251300000X251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========Medicaid