Healthcare Provider Details

I. General information

NPI: 1710527957
Provider Name (Legal Business Name): SOPHISTICATED VENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 NJ-18 SOUTH SUITE 3000
EAST BRUNSWICK NJ
08816
US

IV. Provider business mailing address

197 NJ-18 SOUTH SUITE 3000
EAST BRUNSWICK NJ
08816
US

V. Phone/Fax

Practice location:
  • Phone: 609-369-6425
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ADELINE RUSSULLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 609-369-6425