Healthcare Provider Details

I. General information

NPI: 1063207892
Provider Name (Legal Business Name): ENCHANTED IMPRESSIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 DIETZ ST
ROSELLE NJ
07203-2328
US

IV. Provider business mailing address

440 DIETZ ST
ROSELLE NJ
07203-2328
US

V. Phone/Fax

Practice location:
  • Phone: 973-634-0236
  • Fax:
Mailing address:
  • Phone: 973-634-0236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care 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 Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: TYANA DANIELLE WHITING
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 973-634-0236