Provider Demographics
NPI:1417129057
Name:WELLCARE OF NEW JERSEY, INC.
Entity Type:Organization
Organization Name:WELLCARE OF NEW JERSEY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:IMPECIATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-863-3055
Mailing Address - Street 1:318 W APPLEGATE AVE
Mailing Address - Street 2:PO BOX 318
Mailing Address - City:PEN ARGYL
Mailing Address - State:PA
Mailing Address - Zip Code:18072-1425
Mailing Address - Country:US
Mailing Address - Phone:610-863-3055
Mailing Address - Fax:610-863-3036
Practice Address - Street 1:318 WEST APPLEGATE AVE
Practice Address - Street 2:
Practice Address - City:PEN ARGYL
Practice Address - State:PA
Practice Address - Zip Code:18072-1816
Practice Address - Country:US
Practice Address - Phone:610-863-3055
Practice Address - Fax:610-863-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009640730001Medicaid
PA1009640730001Medicaid