Provider Demographics
NPI:1962071910
Name:FIRST CHOICE RECOVERY CENTER PC
Entity type:Organization
Organization Name:FIRST CHOICE RECOVERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANOJ
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTHIYATHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-956-9483
Mailing Address - Street 1:61 N MAPLE AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3232
Mailing Address - Country:US
Mailing Address - Phone:201-956-9483
Mailing Address - Fax:201-288-5262
Practice Address - Street 1:61 N MAPLE AVE STE 302
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3232
Practice Address - Country:US
Practice Address - Phone:201-956-9483
Practice Address - Fax:201-288-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA09523700OtherSTATE LICENSE