Provider Demographics
NPI:1245384916
Name:SENIOR SPIRIT OF ROSELLE PARK
Entity Type:Organization
Organization Name:SENIOR SPIRIT OF ROSELLE PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GIORDANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-882-1188
Mailing Address - Street 1:28 GIBSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066
Mailing Address - Country:US
Mailing Address - Phone:732-882-1188
Mailing Address - Fax:732-882-0404
Practice Address - Street 1:430 EAST WESTFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:ROSELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07204
Practice Address - Country:US
Practice Address - Phone:908-241-9393
Practice Address - Fax:908-620-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ908117261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care