Provider Demographics
NPI:1922046903
Name:STATE OF NEW JERSEY OMB CENTRALIZED PAYROLL
Entity Type:Organization
Organization Name:STATE OF NEW JERSEY OMB CENTRALIZED PAYROLL
Other - Org Name:NORTH JERSEY DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WERKHEISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-890-4540
Mailing Address - Street 1:PO BOX 169
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07511-0169
Mailing Address - Country:US
Mailing Address - Phone:973-256-1700
Mailing Address - Fax:973-256-7651
Practice Address - Street 1:169 MINNISINK RD
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-1803
Practice Address - Country:US
Practice Address - Phone:973-256-1700
Practice Address - Fax:973-256-7651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ528584OtherMEDICARE BILLING GROUP NO
NJ4497601Medicaid
NJ4497601Medicaid