Provider Demographics
NPI:1346767738
Name:BROADWAY RESPITE AND HOME CARE, LLC
Entity Type:Organization
Organization Name:BROADWAY RESPITE AND HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANASTASIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAYNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-703-3980
Mailing Address - Street 1:17-17 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-703-3980
Mailing Address - Fax:201-703-3984
Practice Address - Street 1:17-17 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-703-3980
Practice Address - Fax:201-703-3984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1266913385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0438341Medicaid