Provider Demographics
NPI:1689076689
Name:FAIRLAWNBRIGHTSTAR
Entity Type:Organization
Organization Name:FAIRLAWNBRIGHTSTAR
Other - Org Name:BRIGHTSTAR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENCY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSTELAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-257-9804
Mailing Address - Street 1:470 CHAMBERLAIN AVE
Mailing Address - Street 2:#5
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07522-1031
Mailing Address - Country:US
Mailing Address - Phone:862-257-9804
Mailing Address - Fax:973-341-7088
Practice Address - Street 1:470 CHAMBERLAIN AVE
Practice Address - Street 2:#5
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07522-1031
Practice Address - Country:US
Practice Address - Phone:862-257-9804
Practice Address - Fax:973-341-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ251E0000X251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ251E0000XOtherHOMEHEALTH