Provider Demographics
NPI:1336305713
Name:EDI
Entity Type:Organization
Organization Name:EDI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-885-0206
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-0301
Mailing Address - Country:US
Mailing Address - Phone:973-885-0206
Mailing Address - Fax:973-761-6624
Practice Address - Street 1:36 NEWARK WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3310
Practice Address - Country:US
Practice Address - Phone:973-885-0206
Practice Address - Fax:973-761-6624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ332B00000X, 332U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies