1336164995 NPI number — FOOD BASICS 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 1336164995 NPI number — FOOD BASICS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOD BASICS 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:
6
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:
1336164995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 416369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-6369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-864-5617
Provider Business Mailing Address Fax Number:
201-864-5623

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1417 KENNEDY BLVD # 27
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH BERGEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07047-6307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-864-5617
Provider Business Practice Location Address Fax Number:
201-864-5623
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIJOWSKI
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, REGULATORY COMPLIANCE
Authorized Official Telephone Number:
201-571-8326

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  06238 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 06238 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3135058 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0008087 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0008095 . This is a "MEDICAID DME" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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