Provider Demographics
NPI:1093043614
Name:WISE HEARING NEW JERSEY
Entity type:Organization
Organization Name:WISE HEARING NEW JERSEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:DARIO
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:AUDIOPROSTHOLOGIST
Authorized Official - Phone:973-589-8341
Mailing Address - Street 1:295A FERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3443
Mailing Address - Country:US
Mailing Address - Phone:973-589-8341
Mailing Address - Fax:973-589-5909
Practice Address - Street 1:295A FERRY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3443
Practice Address - Country:US
Practice Address - Phone:973-589-8341
Practice Address - Fax:973-589-5909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMG00758332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8125503Medicaid