=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225773211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORDILLERA PROFESSIONALS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2022
-----------------------------------------------------
Last Update Date | 05/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 CLAREMONT AVE
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-615-8042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 CLAREMONT AVE
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-615-8042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MARIAH WOOLRIDGE
-----------------------------------------------------
Credential | MANAGER
-----------------------------------------------------
Telephone | 973-615-8042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------