Provider Demographics
NPI:1194298976
Name:AMBROSIA OF NEW JERSEY LLC
Entity type:Organization
Organization Name:AMBROSIA OF NEW JERSEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-947-7351
Mailing Address - Street 1:4821 KATELLA AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720
Mailing Address - Country:US
Mailing Address - Phone:714-828-1800
Mailing Address - Fax:
Practice Address - Street 1:287 OLD MARLTON PIKE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-8761
Practice Address - Country:US
Practice Address - Phone:561-578-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISCOVERY PRACTICE MANAGEMENT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility