=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114048139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATION FOR ADULT FAMILY HEALTH CARE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 ORCHARD ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-1832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-773-7600
-----------------------------------------------------
Fax | 973-773-7011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 ORCHARD ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-1832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-773-7600
-----------------------------------------------------
Fax | 973-773-7011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MR. VIKTORIYA FINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-773-7600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 10113-01-105
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------