Provider Demographics
NPI:1679619126
Name:THERACARE OF NEW JERSEY LLC
Entity Type:Organization
Organization Name:THERACARE OF NEW JERSEY LLC
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:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-564-2350
Mailing Address - Street 1:6981 N PARK DR
Mailing Address - Street 2:WEST BUILDING SUITE 504
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-4205
Mailing Address - Country:US
Mailing Address - Phone:800-393-1306
Mailing Address - Fax:
Practice Address - Street 1:6981 N PARK DR
Practice Address - Street 2:WEST BUILDING SUITE 504
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-4205
Practice Address - Country:US
Practice Address - Phone:800-393-1306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0020214Medicaid