Provider Demographics
NPI:1720124860
Name:SOCIAL CLUBHOUSE, INC.
Entity Type:Organization
Organization Name:SOCIAL CLUBHOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-376-2500
Mailing Address - Street 1:58 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-2902
Mailing Address - Country:US
Mailing Address - Phone:973-376-2500
Mailing Address - Fax:973-376-5737
Practice Address - Street 1:58 BROWN AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-2902
Practice Address - Country:US
Practice Address - Phone:973-376-2500
Practice Address - Fax:973-376-5737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6782906Medicaid