1558488908 NPI number — AMAZING GRACE NURSING CARE SERVICE

Table of content: (NPI 1558488908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558488908 NPI number — AMAZING GRACE NURSING CARE SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMAZING GRACE NURSING CARE SERVICE
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:
AMAZING GRACE NURSING CARE SERVICE
Provider Other Organization Name Type Code:
4
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:
1558488908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2165 MORRIS AVE STE 1A
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:
07083-5920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-206-9988
Provider Business Mailing Address Fax Number:
908-206-9986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2165 MORRIS AVE STE 1A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNION
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07083-5920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-206-9988
Provider Business Practice Location Address Fax Number:
908-206-9986
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
UDOYEN
Authorized Official First Name:
ISAAC
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
908-206-9988

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HP0024800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X , with the licence number: HP0024800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: HP0024800 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0096164 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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