Provider Demographics
NPI:1962544734
Name:MI CASA ES SU CASA, INC.
Entity type:Organization
Organization Name:MI CASA ES SU CASA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-652-8434
Mailing Address - Street 1:30 S MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4508
Mailing Address - Country:US
Mailing Address - Phone:201-652-8434
Mailing Address - Fax:201-652-0194
Practice Address - Street 1:911 E 23RD ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07513-1500
Practice Address - Country:US
Practice Address - Phone:973-345-4300
Practice Address - Fax:973-345-8811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ708110314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6799701Medicaid