Provider Demographics
NPI:1922217322
Name:HENDRICKS HOUSE, INC.
Entity Type:Organization
Organization Name:HENDRICKS HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MSM, LCADC
Authorized Official - Phone:856-794-2443
Mailing Address - Street 1:542 N. WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360
Mailing Address - Country:US
Mailing Address - Phone:856-794-2443
Mailing Address - Fax:856-794-8887
Practice Address - Street 1:542 N WEST BLVD
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-2847
Practice Address - Country:US
Practice Address - Phone:856-794-2443
Practice Address - Fax:856-205-9277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1000007-07324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ005515Medicaid
NJ7609507Medicaid