Provider Demographics
NPI:1699002865
Name:SOUTHGATE RESIDENTIAL LIFE CENTER
Entity Type:Organization
Organization Name:SOUTHGATE RESIDENTIAL LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-288-6398
Mailing Address - Street 1:2630 ROUTE 206
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-6708
Mailing Address - Country:US
Mailing Address - Phone:609-288-6398
Mailing Address - Fax:
Practice Address - Street 1:2630 ROUTE 206
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-6708
Practice Address - Country:US
Practice Address - Phone:609-288-6398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1700049475OtherINDIVIDUAL
NJ1946510Medicaid