Provider Demographics
NPI:1144915786
Name:PENN 123 LLC
Entity type:Organization
Organization Name:PENN 123 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YEHUDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-307-8000
Mailing Address - Street 1:211 BOULEVARD OF THE AMERICAS
Mailing Address - Street 2:SUITE 503
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701
Mailing Address - Country:US
Mailing Address - Phone:732-307-8000
Mailing Address - Fax:
Practice Address - Street 1:4933 WABASH ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1031
Practice Address - Country:US
Practice Address - Phone:504-603-3060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility