Healthcare Provider Details

I. General information

NPI: 1023908118
Provider Name (Legal Business Name): IRIDIOUS CHARLES HALLBACK JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CLERMONT AVE
EWING NJ
08618-2615
US

IV. Provider business mailing address

3 CLERMONT AVE
EWING NJ
08618-2615
US

V. Phone/Fax

Practice location:
  • Phone: 609-743-1912
  • Fax:
Mailing address:
  • Phone: 609-743-1912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: