Provider Demographics
NPI:1346454113
Name:RENAISSANCE INVALID COACH
Entity Type:Organization
Organization Name:RENAISSANCE INVALID COACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOJTABA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSEMALSEED
Authorized Official - Suffix:
Authorized Official - Credentials:CPR, MAVT
Authorized Official - Phone:973-497-0045
Mailing Address - Street 1:PO BOX 22711
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-2711
Mailing Address - Country:US
Mailing Address - Phone:973-497-0045
Mailing Address - Fax:973-497-1155
Practice Address - Street 1:226 LINCOLN AVE
Practice Address - Street 2:# 10
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3452
Practice Address - Country:US
Practice Address - Phone:973-497-0045
Practice Address - Fax:973-497-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRENA00492343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7356501Medicaid