1790840130 NPI number — ROSE GARDEN NUTRITION INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790840130 NPI number — ROSE GARDEN NUTRITION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSE GARDEN NUTRITION INC
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:
Provider Other Organization Name Type Code:
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:
1790840130
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:
P.O. 1660
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNION
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07083-1660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-645-0388
Provider Business Mailing Address Fax Number:
973-624-3411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 ELIZABETH AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-645-0388
Provider Business Practice Location Address Fax Number:
973-624-3411
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALY
Authorized Official First Name:
AHMED
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
973-645-0388

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  28RS00623700 , 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: 9106812 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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