Provider Demographics
NPI:1205058567
Name:MARYVILLE, INC.
Entity type:Organization
Organization Name:MARYVILLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCADC
Authorized Official - Phone:256-227-2717
Mailing Address - Street 1:567 SALEM-QUINTON RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NJ
Mailing Address - Zip Code:08079
Mailing Address - Country:US
Mailing Address - Phone:856-935-9305
Mailing Address - Fax:856-935-9269
Practice Address - Street 1:567 SALEM-QUINTON RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079
Practice Address - Country:US
Practice Address - Phone:856-935-9305
Practice Address - Fax:856-935-9269
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYVILLE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ23016261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7632401Medicaid