1134128309 NPI number — WANAQUE OPERATING CO, L.P.

Table of content: (NPI 1134128309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134128309 NPI number — WANAQUE OPERATING CO, L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WANAQUE OPERATING CO, L.P.
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:
THE WANAQUE CENTER
Provider Other Organization Name Type Code:
3
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:
1134128309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1433 RINGWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HASKELL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07420-1520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-839-2119
Provider Business Mailing Address Fax Number:
856-665-5708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1114 WYNNWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08002-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-663-4044
Provider Business Practice Location Address Fax Number:
856-665-5708
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
LENARD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR. ACCOUNT RECEIVABLE
Authorized Official Telephone Number:
856-663-4044

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  061628 , 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: 4495713 . This is a "RES-PROV" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4496001 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01292924 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4495705 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0306070 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01057345 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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