=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245754084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUL HOUSE CRUBER WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1144 CLINTON AVENUE
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-218-6710
-----------------------------------------------------
Fax | 973-399-3613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1144 CLINTON AVE
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-218-6710
-----------------------------------------------------
Fax | 973-399-3613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. ALI RASHID
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 973-399-3100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 37LC00170100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------