Basic Information
| Provider Information | |||||||||
| NPI: | 1477797595 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HABIT OPCO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | NEW STREET | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 639 GRANITE ST | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021845366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813568017 | ||||||||
| FaxNumber: | 7813568052 | ||||||||
| Practice Location | |||||||||
| Address1: | 57 NEW ST | ||||||||
| Address2: | |||||||||
| City: | IRVINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071112444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733732010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 04/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | APRUZZESE | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7813568017 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 2000004 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0191272 | 05 | NJ | MEDICAID |