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General NPI Number Information
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NPI Number | 1093444721
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Entity Type | Organization
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Legal Business Name | JERSEY STAKE LLC
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Dates
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Enumeration Date | 06/08/2022
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 2125 CENTER AVE STE 110
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City | FORT LEE
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State | NJ
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Zip | 07024-5821
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Country | US
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Telephone | 201-242-0305
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Fax | 201-242-0345
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Provider Business Mailing Address
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Address Line | 19 ORCHARD PL
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City | HAWTHORNE
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State | NJ
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Zip | 07506-3123
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL TUCCI
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Credential |
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Telephone | 201-242-0305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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