Provider Demographics
NPI:1679223176
Name:POTENTIAL UNCHARTED
Entity Type:Organization
Organization Name:POTENTIAL UNCHARTED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-672-3973
Mailing Address - Street 1:2 ARNOT ST UNIT 455
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-1629
Mailing Address - Country:US
Mailing Address - Phone:914-672-3973
Mailing Address - Fax:
Practice Address - Street 1:2 ARNOT ST UNIT 455
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-1629
Practice Address - Country:US
Practice Address - Phone:914-672-3973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-27
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services