Provider Demographics
NPI:1093229064
Name:PERSONALIZED POTENTIAL CENTER
Entity type:Organization
Organization Name:PERSONALIZED POTENTIAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PIOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-956-0039
Mailing Address - Street 1:20 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1031
Mailing Address - Country:US
Mailing Address - Phone:201-956-0039
Mailing Address - Fax:
Practice Address - Street 1:20 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-1031
Practice Address - Country:US
Practice Address - Phone:201-956-0039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
No332900000XSuppliersNon-Pharmacy Dispensing Site
No347C00000XTransportation ServicesPrivate Vehicle
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========Medicaid
NJ=========OtherALL OTHER INSURANCE COMPANIES