Provider Demographics
NPI:1922518299
Name:MARYVILLE, INC
Entity Type:Organization
Organization Name:MARYVILLE, INC
Other - Org Name:MARYVILLE ADDICTION TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:VEONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-863-3913
Mailing Address - Street 1:129 JOHNSON RD STE 7
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-1777
Mailing Address - Country:US
Mailing Address - Phone:856-863-3913
Mailing Address - Fax:
Practice Address - Street 1:129 JOHNSON RD STE 7
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-1777
Practice Address - Country:US
Practice Address - Phone:856-863-3913
Practice Address - Fax:856-863-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000132261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0185485Medicaid