Provider Demographics
NPI:1013623107
Name:PRISTINE CARE & SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:PRISTINE CARE & SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VENTLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-224-1099
Mailing Address - Street 1:3121 FIRE RD STE D310
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-9619
Mailing Address - Country:US
Mailing Address - Phone:609-224-1099
Mailing Address - Fax:609-224-1099
Practice Address - Street 1:3121 FIRE RD STE D310
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-9619
Practice Address - Country:US
Practice Address - Phone:609-224-1099
Practice Address - Fax:609-224-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities