Healthcare Provider Details

I. General information

NPI: 1306339882
Provider Name (Legal Business Name): FRONTIER TRAVEL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 N PARK ST # 2
EAST ORANGE NJ
07017-1800
US

IV. Provider business mailing address

190 N PARK ST # 2
EAST ORANGE NJ
07017-1800
US

V. Phone/Fax

Practice location:
  • Phone: 973-445-5950
  • Fax:
Mailing address:
  • Phone: 973-445-5950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateNJ

VIII. Authorized Official

Name: MELODY F BUNDY
Title or Position: DIRECTOR
Credential:
Phone: 973-445-5950