Healthcare Provider Details

I. General information

NPI: 1194345025
Provider Name (Legal Business Name): HOLY MOBA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 W 3RD AVE APT 13
ROSELLE NJ
07203-1268
US

IV. Provider business mailing address

485C US HIGHWAY 1 S STE 100
ISELIN NJ
08830-3016
US

V. Phone/Fax

Practice location:
  • Phone: 973-289-3614
  • Fax:
Mailing address:
  • Phone: 973-289-3614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MERCY A GBORSON
Title or Position: MANAGING MEMBER
Credential:
Phone: 973-289-3614