Provider Demographics
NPI:1164766507
Name:OLYMPIC GROUP HOME AND HOMECARE SERVICES
Entity Type:Organization
Organization Name:OLYMPIC GROUP HOME AND HOMECARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:K
Authorized Official - Last Name:NYATOME
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:201-522-6526
Mailing Address - Street 1:105 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5201
Mailing Address - Country:US
Mailing Address - Phone:201-522-6526
Mailing Address - Fax:
Practice Address - Street 1:105 WOODLAND ROAD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:201-522-6526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0400510330171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty