Provider Demographics
NPI:1457573842
Name:MARYVILLE, INC.
Entity Type:Organization
Organization Name:MARYVILLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-863-3913
Mailing Address - Street 1:1173 EAST LANDIS AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360
Mailing Address - Country:US
Mailing Address - Phone:856-690-1000
Mailing Address - Fax:856-690-1764
Practice Address - Street 1:1173 EAST LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360
Practice Address - Country:US
Practice Address - Phone:856-690-1000
Practice Address - Fax:856-690-1764
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYVILLE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22932261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7706405Medicaid