Provider Demographics
NPI:1477999712
Name:IYAHO SOCIAL SERVICES INCORPORATION
Entity Type:Organization
Organization Name:IYAHO SOCIAL SERVICES INCORPORATION
Other - Org Name:NA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:EROMOSELE
Authorized Official - Suffix:
Authorized Official - Credentials:EXECUTIVE DIRECTOR
Authorized Official - Phone:516-280-5930
Mailing Address - Street 1:71 N FRANKLIN ST # 211
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-3048
Mailing Address - Country:US
Mailing Address - Phone:516-280-5930
Mailing Address - Fax:516-280-5933
Practice Address - Street 1:137 EVERGREEN PL # 3
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2005
Practice Address - Country:US
Practice Address - Phone:917-601-0669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10103TM1800X
NJ2510000X251C00000X
NJ25252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========Medicaid