=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912762261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDINAL SUPPORT SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2024
-----------------------------------------------------
Last Update Date | 02/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 ELM LN
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-907-3210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1633
-----------------------------------------------------
City | PT PLEASANT BEACH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08742-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-907-3210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DONNA VANDERVEER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-907-3210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------