Provider Demographics
NPI:1700319845
Name:SOVEREIGNTY SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:SOVEREIGNTY SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LENNOX
Authorized Official - Middle Name:ALPHANSO
Authorized Official - Last Name:MARS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MPA
Authorized Official - Phone:862-233-3596
Mailing Address - Street 1:70 W GRAND ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1988
Mailing Address - Country:US
Mailing Address - Phone:862-233-3596
Mailing Address - Fax:888-767-9772
Practice Address - Street 1:70 W GRAND ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-1988
Practice Address - Country:US
Practice Address - Phone:862-233-3596
Practice Address - Fax:888-767-9772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1700319845Medicaid