1366742868 NPI number — EMBRACE PSYCHIATRIC WELLNESS CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366742868 NPI number — EMBRACE PSYCHIATRIC WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMBRACE PSYCHIATRIC WELLNESS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LEOPOLD J BOLONA MD LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366742868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
354 SOUTH AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07090-1788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-233-8065
Provider Business Mailing Address Fax Number:
908-233-8042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
354 SOUTH AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07090-1788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-233-8065
Provider Business Practice Location Address Fax Number:
908-233-8042
Provider Enumeration Date:
10/30/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOLONA
Authorized Official First Name:
LEOPOLD
Authorized Official Middle Name:
JORGE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
908-233-8065

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  25MA08702100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)