Healthcare Provider Details

I. General information

NPI: 1114266269
Provider Name (Legal Business Name): ULTRACARE FAMILY WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2013
Last Update Date: 02/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 WHITEWOOD RD
UNION NJ
07083-8217
US

IV. Provider business mailing address

404 WHITEWOOD RD
UNION NJ
07083-8217
US

V. Phone/Fax

Practice location:
  • Phone: 646-894-4166
  • Fax:
Mailing address:
  • Phone: 646-894-4166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0400317931
License Number StateNJ

VIII. Authorized Official

Name: MR. DESMOND JOHNSON
Title or Position: PRESIDENT/FOUNDER
Credential: MBA
Phone: 646-894-4166