Provider Demographics
NPI:1053702829
Name:YOUR 365 SUPPORTIVE COORDINATION CARE
Entity type:Organization
Organization Name:YOUR 365 SUPPORTIVE COORDINATION CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:FERMINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDOX-MOHAMMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-344-5089
Mailing Address - Street 1:1 OAK LEAF CT
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5285
Mailing Address - Country:US
Mailing Address - Phone:856-344-5089
Mailing Address - Fax:
Practice Address - Street 1:1 OAK LEAF CT
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5285
Practice Address - Country:US
Practice Address - Phone:856-344-5089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUR 365 SUPPORTIVE COORDINATION CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care