Healthcare Provider Details

I. General information

NPI: 1225773211
Provider Name (Legal Business Name): CORDILLERA PROFESSIONALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 CLAREMONT AVE
MONTCLAIR NJ
07042-1801
US

IV. Provider business mailing address

403 CLAREMONT AVE
MONTCLAIR NJ
07042-1801
US

V. Phone/Fax

Practice location:
  • Phone: 973-615-8042
  • Fax:
Mailing address:
  • Phone: 973-615-8042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MARIAH WOOLRIDGE
Title or Position: MANAGER
Credential: MANAGER
Phone: 973-615-8042