Healthcare Provider Details

I. General information

NPI: 1164132148
Provider Name (Legal Business Name): FIVIC SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 PASSAIC AVE
BELLEVILLE NJ
07109-1960
US

IV. Provider business mailing address

209 PASSAIC AVE
BELLEVILLE NJ
07109-1960
US

V. Phone/Fax

Practice location:
  • Phone: 973-392-0430
  • Fax:
Mailing address:
  • Phone: 973-392-0430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: AMA J BAFFOE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 973-392-0430