Healthcare Provider Details

I. General information

NPI: 1104096445
Provider Name (Legal Business Name): NEUROWAVE PROFILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 NEWARK AVE
JERSEY CITY NJ
07306-2302
US

IV. Provider business mailing address

PO BOX 441
ORADELL NJ
07649-0441
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-1205
  • Fax: 211-342-1259
Mailing address:
  • Phone: 201-342-1205
  • Fax: 201-342-1259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DANILO MANGUNAY
Title or Position: PRESIDENT
Credential: MD
Phone: 201-342-1205