Provider Demographics
NPI:1124122353
Name:GOCOPETRA CARE CONSULTANT LLC
Entity type:Organization
Organization Name:GOCOPETRA CARE CONSULTANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:COMFORT
Authorized Official - Middle Name:NWAMAKA
Authorized Official - Last Name:EKUNNO-TABANSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-731-7938
Mailing Address - Street 1:540 HILLSIDE TER
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4306
Mailing Address - Country:US
Mailing Address - Phone:973-731-7938
Mailing Address - Fax:973-324-2218
Practice Address - Street 1:170 NORWOOD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-2627
Practice Address - Country:US
Practice Address - Phone:201-491-9972
Practice Address - Fax:973-324-2218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL927499133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097991Medicare PIN