Provider Demographics
NPI:1821457060
Name:SUPPORTIVE CARE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:SUPPORTIVE CARE MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHADE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-262-1200
Mailing Address - Street 1:1330 N BLACK HORSE PIKE
Mailing Address - Street 2:SUITE- C
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-9160
Mailing Address - Country:US
Mailing Address - Phone:856-262-1200
Mailing Address - Fax:856-262-1204
Practice Address - Street 1:1330 N BLACK HORSE PIKE
Practice Address - Street 2:SUITE- C
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-9160
Practice Address - Country:US
Practice Address - Phone:856-262-1200
Practice Address - Fax:856-262-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0450052392251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management