Provider Demographics
NPI:1184192445
Name:WISE HEARING NEW JERSEY LLC
Entity Type:Organization
Organization Name:WISE HEARING NEW JERSEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOPROSTHOLOGIST/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:DARIO
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:ACA, DC-HIS
Authorized Official - Phone:201-428-9242
Mailing Address - Street 1:600 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002
Mailing Address - Country:US
Mailing Address - Phone:201-455-2649
Mailing Address - Fax:201-455-2651
Practice Address - Street 1:179 KEARNEY AVE
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032
Practice Address - Country:US
Practice Address - Phone:201-428-9242
Practice Address - Fax:201-428-9244
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISE HEARING NEW JERSEY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0295850Medicaid