Provider Demographics
NPI:1205557790
Name:N/A
Entity type:Organization
Organization Name:N/A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMWEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GITONGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:848-203-8264
Mailing Address - Street 1:304 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:CARTERET
Mailing Address - State:NJ
Mailing Address - Zip Code:07008-3025
Mailing Address - Country:US
Mailing Address - Phone:848-203-8264
Mailing Address - Fax:
Practice Address - Street 1:304 PERSHING AVE
Practice Address - Street 2:
Practice Address - City:CARTERET
Practice Address - State:NJ
Practice Address - Zip Code:07008-3025
Practice Address - Country:US
Practice Address - Phone:848-203-8264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities