Provider Demographics
NPI:1073979167
Name:ST MARK HOME CARE LLC
Entity Type:Organization
Organization Name:ST MARK HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAFIK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAKHOURI
Authorized Official - Suffix:
Authorized Official - Credentials:MR
Authorized Official - Phone:201-424-4847
Mailing Address - Street 1:895 BERGEN AVE
Mailing Address - Street 2:307
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-4309
Mailing Address - Country:US
Mailing Address - Phone:201-424-4847
Mailing Address - Fax:201-758-7778
Practice Address - Street 1:895 BERGEN AVE
Practice Address - Street 2:307
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-4309
Practice Address - Country:US
Practice Address - Phone:201-424-4847
Practice Address - Fax:201-758-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJHP0175700251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJHP017500OtherLICENSE
NJ=========OtherTAX ID