Healthcare Provider Details

I. General information

NPI: 1346814811
Provider Name (Legal Business Name): ADVANCE DIVINE HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/18/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 BERKELEY TER
PLAINFIELD NJ
07062-1516
US

IV. Provider business mailing address

138 LAWRENCE ST
NEW BRUNSWICK NJ
08901-3161
US

V. Phone/Fax

Practice location:
  • Phone: 732-354-3313
  • Fax: 732-354-3314
Mailing address:
  • Phone: 732-447-4085
  • Fax: 732-354-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. CELESTINE U OHALE
Title or Position: ADMINISTRATOR
Credential: MR
Phone: 732-447-4085