Provider Demographics
NPI:1710671979
Name:THE CLUB OF BERGEN COUNTY
Entity Type:Organization
Organization Name:THE CLUB OF BERGEN COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GENDY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:201-234-9105
Mailing Address - Street 1:22-08 ROUTE 208 STE 8
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22-08 ROUTE 208 STE 8
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2609
Practice Address - Country:US
Practice Address - Phone:201-773-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-08
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No385H00000XRespite Care FacilityRespite Care