1811413883 NPI number — BEACON OF WELLNESS, INCORPORATED

Table of content: (NPI 1811413883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811413883 NPI number — BEACON OF WELLNESS, INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON OF WELLNESS, INCORPORATED
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:
1811413883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1636-44 ROUTE 38, BEACON OF WELLNESS, INC.
Provider Second Line Business Mailing Address:
#334
Provider Business Mailing Address City Name:
LUMBERTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-784-4682
Provider Business Mailing Address Fax Number:
609-699-6744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 W LAFAYETTE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRENTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08608-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-784-4682
Provider Business Practice Location Address Fax Number:
609-699-6744
Provider Enumeration Date:
08/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN-DAY
Authorized Official First Name:
MADINAH
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
609-784-4682

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  44SL05979800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 44SL06293100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 44SL06288800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 44SC05349200 , 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: 0509060 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1629476692 . This is a "INDIVIDUAL NPI # FOR MADINAH BROWN-DAY" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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