Organization
SOUTHGATE RESIDENTIAL LIFE CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LAWRENCE DAVIS (MEMBER)
(609) 288-6398
Entity
Organization
Contact information
Practice address
2630 ROUTE 206, MOUNT HOLLY, NJ 08060-6708
(609) 288-6398
Mailing address
2630 ROUTE 206, MOUNT HOLLY, NJ 08060-6708
(609) 288-6398
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1700049475
INDIVIDUAL
NJ
05
—
1946510
—
NJ
Enumeration date
11/10/2009
Last updated
11/10/2009
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