Provider Demographics
NPI:1598997520
Name:SAN JUAN HEART, LLC
Entity Type:Organization
Organization Name:SAN JUAN HEART, LLC
Other - Org Name:SAINT JOHN
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-458-8292
Mailing Address - Street 1:39 AYCRIGG AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-5664
Mailing Address - Country:US
Mailing Address - Phone:973-458-8292
Mailing Address - Fax:973-777-1637
Practice Address - Street 1:625 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4952
Practice Address - Country:US
Practice Address - Phone:973-458-8292
Practice Address - Fax:973-777-1637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-09
Last Update Date:2009-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJHP0046601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJHP0046601OtherHP