Provider Demographics
NPI:1811359060
Name:FOUR WALLS THE 4WALLS LLC
Entity type:Organization
Organization Name:FOUR WALLS THE 4WALLS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:BRICE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MED
Authorized Official - Phone:856-650-6556
Mailing Address - Street 1:PO BOX 201
Mailing Address - Street 2:
Mailing Address - City:SOMERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08083-0201
Mailing Address - Country:US
Mailing Address - Phone:856-650-6556
Mailing Address - Fax:
Practice Address - Street 1:2511 HAMILTON DR
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-2642
Practice Address - Country:US
Practice Address - Phone:856-650-6556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-27
Last Update Date:2016-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0400647708251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health