Provider Demographics
NPI:1477092526
Name:WISE HEARING NEW JERSEY LLC
Entity Type:Organization
Organization Name:WISE HEARING NEW JERSEY LLC
Other - Org Name:WISE HEARING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUDIOPROSTHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:DARIO
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:ACA, BC-HIS
Authorized Official - Phone:201-758-7853
Mailing Address - Street 1:60 CRANE AVE
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2538
Mailing Address - Country:US
Mailing Address - Phone:201-779-2413
Mailing Address - Fax:
Practice Address - Street 1:8421 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-6517
Practice Address - Country:US
Practice Address - Phone:201-758-7853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00075800261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center