Healthcare Provider Details

I. General information

NPI: 1477999712
Provider Name (Legal Business Name): IYAHO SOCIAL SERVICES INCORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 EVERGREEN PL # 3
EAST ORANGE NJ
07018-2005
US

IV. Provider business mailing address

71 N FRANKLIN ST # 211
HEMPSTEAD NY
11550-3048
US

V. Phone/Fax

Practice location:
  • Phone: 917-601-0669
  • Fax:
Mailing address:
  • Phone: 516-280-5930
  • Fax: 516-280-5933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number2510000X
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number10
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number25
License Number StateNJ

VIII. Authorized Official

Name: HENRY EROMOSELE
Title or Position: EXECUTIVE DIRECTOR
Credential: EXECUTIVE DIRECTOR
Phone: 516-280-5930