Provider Demographics
NPI:1174868103
Name:WISE HEARING NEW JERSEY LLC
Entity Type:Organization
Organization Name:WISE HEARING NEW JERSEY LLC
Other - Org Name:WISE HEARING
Other - Org Type:Other Name
Authorized Official - Title/Position:AUDIOPROSTHOLOGIST
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:ACA, BC-HIS
Authorized Official - Phone:201-779-2413
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:973-732-2236
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:973-732-2236
Practice Address - Fax:973-589-5909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00075800237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0297658Medicaid