=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285277640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENOTDIS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2019
-----------------------------------------------------
Last Update Date | 10/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 E MAIN ST
-----------------------------------------------------
City | MENDHAM
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07945-1539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-500-1102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 E MAIN ST
-----------------------------------------------------
City | MENDHAM
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07945-1539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-500-1102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | RANDALL VALENTINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 862-500-1102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------