1003024019 NPI number — FOOT CARE OF JERSEY CORPORATION

Table of content: (NPI 1003024019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003024019 NPI number — FOOT CARE OF JERSEY CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT CARE OF JERSEY CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PATRICK CAIN
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003024019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
669 BROADWAY
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
PATERSON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07514-1947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-689-7091
Provider Business Mailing Address Fax Number:
973-689-7561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
669 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PATERSON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07514-1947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-689-7091
Provider Business Practice Location Address Fax Number:
973-689-7561
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CAIN
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
973-689-7091

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  25MD00284800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0121185 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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