Provider Demographics
NPI:1427039379
Name:WELLCARE OF NEW JERSEY, INC.
Entity Type:Organization
Organization Name:WELLCARE OF NEW JERSEY, INC.
Other - Org Name:WELLCARE HOME MOBILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-777-3196
Mailing Address - Street 1:410 GARIBALDI AVE
Mailing Address - Street 2:UNIT B
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-3710
Mailing Address - Country:US
Mailing Address - Phone:973-777-3196
Mailing Address - Fax:973-777-3195
Practice Address - Street 1:410 GARIBALDI AVE
Practice Address - Street 2:UNIT B
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-3710
Practice Address - Country:US
Practice Address - Phone:973-777-3196
Practice Address - Fax:973-777-3195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3000007639332B00000X
NJ332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8866309Medicaid
PA1009640730001Medicaid
NJ4291610001Medicare ID - Type Unspecified
PA1009640730001Medicaid