Provider Demographics
NPI:1053793463
Name:SPECTRUM FOR LIVING GROUP HOMES INC.
Entity type:Organization
Organization Name:SPECTRUM FOR LIVING GROUP HOMES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-358-5063
Mailing Address - Street 1:210 RIVERVALE RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RIVERVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6281
Mailing Address - Country:US
Mailing Address - Phone:201-358-8000
Mailing Address - Fax:201-358-8089
Practice Address - Street 1:81 RIVERVALE RD
Practice Address - Street 2:
Practice Address - City:RIVERVALE
Practice Address - State:NJ
Practice Address - Zip Code:07675-6214
Practice Address - Country:US
Practice Address - Phone:201-722-0904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSA555320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities