Healthcare Provider Details

I. General information

NPI: 1396128195
Provider Name (Legal Business Name): E GLISE EVANGELIGUE EBEN EZER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 CENTRAL AVENUE
EAST ORANGE NJ
07018
US

IV. Provider business mailing address

188 CENTRAL AVENUE
EAST ORANGE NJ
07018
US

V. Phone/Fax

Practice location:
  • Phone: 973-776-2205
  • Fax: 862-930-3135
Mailing address:
  • Phone: 973-776-2205
  • Fax: 862-930-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL LAURENT
Title or Position: ADMINISTRATOR
Credential:
Phone: 973-609-7714