Healthcare Provider Details

I. General information

NPI: 1770911471
Provider Name (Legal Business Name): EXPERIENCED SUPPORT COORDINATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 JONI AVE
HAMILTON NJ
08690-3641
US

IV. Provider business mailing address

108 JONI AVE
HAMILTON NJ
08690-3641
US

V. Phone/Fax

Practice location:
  • Phone: 609-581-1614
  • Fax:
Mailing address:
  • Phone: 609-581-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS LENCOVICH
Title or Position: PRESIDENT
Credential:
Phone: 609-581-1614