Provider Demographics
NPI:1700088226
Name:MY FATHER'S HOUSE, INC
Entity Type:Organization
Organization Name:MY FATHER'S HOUSE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCADC, CCS
Authorized Official - Phone:856-742-0900
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-0230
Mailing Address - Country:US
Mailing Address - Phone:856-742-0900
Mailing Address - Fax:856-742-0811
Practice Address - Street 1:104 N KING ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER CITY
Practice Address - State:NJ
Practice Address - Zip Code:08030-1417
Practice Address - Country:US
Practice Address - Phone:856-742-0900
Practice Address - Fax:856-742-0811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7601905Medicaid