Provider Demographics
NPI:1649857186
Name:BAMBARA, VIVION LARRY
Entity type:Individual
Prefix:
First Name:VIVION
Middle Name:LARRY
Last Name:BAMBARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E GIBBSBORO RD APT 1611
Mailing Address - Street 2:
Mailing Address - City:LINDENWOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-1923
Mailing Address - Country:US
Mailing Address - Phone:346-262-7732
Mailing Address - Fax:
Practice Address - Street 1:101 E GIBBSBORO RD APT 1611
Practice Address - Street 2:
Practice Address - City:LINDENWOLD
Practice Address - State:NJ
Practice Address - Zip Code:08021-1923
Practice Address - Country:US
Practice Address - Phone:346-262-7732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 261QA0600X
NJ320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1649857186Medicaid