=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831617026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROADWAY RESPITE AND HOME CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2017
-----------------------------------------------------
Last Update Date | 03/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1007 LIVINGSTON AVE
-----------------------------------------------------
City | NORTH BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-703-3980
-----------------------------------------------------
Fax | 201-703-3984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17-17 BROADWAY
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-703-3980
-----------------------------------------------------
Fax | 201-703-3984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | ANASTASIA VAYNBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-703-3980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------