1073779658 NPI number — CENTER FOR ADULT MEDICINE AND PREVENTIVE CARE, PC

Table of content: (NPI 1073779658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073779658 NPI number — CENTER FOR ADULT MEDICINE AND PREVENTIVE CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR ADULT MEDICINE AND PREVENTIVE CARE, PC
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:
Provider Other Organization Name Type Code:
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:
1073779658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
916-922 MAIN AVE
Provider Second Line Business Mailing Address:
SUITE 1A
Provider Business Mailing Address City Name:
PASSAIC
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07055-8544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-773-0334
Provider Business Mailing Address Fax Number:
973-773-0336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
916-922 MAIN AVE
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
PASSAIC
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07055-8544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-773-0334
Provider Business Practice Location Address Fax Number:
973-773-0336
Provider Enumeration Date:
08/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TEJEDA
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
ALBERTO
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
718-704-8983

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 135720 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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