Provider Demographics
NPI:1184978397
Name:PROVIDENCE PLACE PCH
Entity type:Organization
Organization Name:PROVIDENCE PLACE PCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR CATHOLIC CHARITI
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-639-6678
Mailing Address - Street 1:75 GREENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-2607
Mailing Address - Country:US
Mailing Address - Phone:973-639-6678
Mailing Address - Fax:
Practice Address - Street 1:75 GREENVILLE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-2607
Practice Address - Country:US
Practice Address - Phone:973-639-6678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC CHARITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-09
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility