Basic Information
| Provider Information | |||||||||
| NPI: | 1962544734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MI CASA ES SU CASA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 S MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074504508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016528434 | ||||||||
| FaxNumber: | 2016520194 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | PATERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 075131500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733454300 | ||||||||
| FaxNumber: | 9733458811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GINES | ||||||||
| AuthorizedOfficialFirstName: | ANTONIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2016528434 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 708110 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 6799701 | 05 | NJ | MEDICAID |