Provider Demographics
NPI:1053018317
Name:EUCALYPTUS ONE LLC
Entity type:Organization
Organization Name:EUCALYPTUS ONE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FERMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-224-7347
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07418-0092
Mailing Address - Country:US
Mailing Address - Phone:917-909-9449
Mailing Address - Fax:
Practice Address - Street 1:1 VERNON VIEW DR W
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07418-1010
Practice Address - Country:US
Practice Address - Phone:917-909-9449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-07
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health