Healthcare Provider Details

I. General information

NPI: 1164548871
Provider Name (Legal Business Name): ADVANTAGE HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 STATE STREET
HACKENSACK NJ
07601
US

IV. Provider business mailing address

270 STATE STREET
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 201-489-4899
  • Fax:
Mailing address:
  • Phone: 201-489-4899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHP0058600
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0061646
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: MR. LEONARD VERKHOGLAZ
Title or Position: PRINCIPAL
Credential:
Phone: 201-489-4899