Provider Demographics
NPI:1700942547
Name:ST. PETER'S ORPHANAGE, INC.
Entity Type:Organization
Organization Name:ST. PETER'S ORPHANAGE, INC.
Other - Org Name:ST. PETER'S VILLAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:SQUEO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-627-0212
Mailing Address - Street 1:170 DIAMOND SPRING RD
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 DIAMOND SPRING RD
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2910
Practice Address - Country:US
Practice Address - Phone:973-627-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1620322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8385106Medicaid