Provider Demographics
NPI:1306346325
Name:MARYVILLE, INC
Entity type:Organization
Organization Name:MARYVILLE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-863-3913
Mailing Address - Street 1:129 JOHNSON RD STE 7
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-1777
Mailing Address - Country:US
Mailing Address - Phone:856-863-3913
Mailing Address - Fax:
Practice Address - Street 1:610 PEMBERTON BROWNS MILLS RD
Practice Address - Street 2:
Practice Address - City:PEMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08068
Practice Address - Country:US
Practice Address - Phone:609-321-6263
Practice Address - Fax:609-283-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1000140324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1000140OtherSTATE OF NEW JERSEY OFFICE OF LICENSING