Basic Information
Provider Information | |||||||||
NPI: | 1720110588 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOWNCO CONSULTANTS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | YOUNG AT HEART OF BRICK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ASBURY PARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 077126518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7327754462 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2125 ROUTE 88 | ||||||||
Address2: |   | ||||||||
City: | BRICK | ||||||||
State: | NJ | ||||||||
PostalCode: | 087243227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7328991331 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOLDBERG | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7327754462 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | 658335 | NJ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
ID | Type | State | Issuer | Description | 0011011 | 05 | NJ |   | MEDICAID |