=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225418098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 360 DEGREE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2015
-----------------------------------------------------
Last Update Date | 06/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 CHESTNUT ST
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-3872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-299-4243
-----------------------------------------------------
Fax | 201-299-6521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 CHESTNUT ST
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-3872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-299-4243
-----------------------------------------------------
Fax | 201-299-6521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MR. JEFF DEJOSEPH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-299-4243
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HPO194700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------