=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689076689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRLAWNBRIGHTSTAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2014
-----------------------------------------------------
Last Update Date | 09/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 470 CHAMBERLAIN AVE #5
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07522-1031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-257-9804
-----------------------------------------------------
Fax | 973-341-7088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 470 CHAMBERLAIN AVE #5
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07522-1031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-257-9804
-----------------------------------------------------
Fax | 973-341-7088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AGENCY MANAGER
-----------------------------------------------------
Name | MR. JERRY BOSTELAAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 862-257-9804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 251E0000X
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------