1477796191 NPI number — NEWLY DESTINED, INC.

Table of content: DR. SALLY VALENTINA MATHIAS MD (NPI 1225321789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477796191 NPI number — NEWLY DESTINED, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEWLY DESTINED, INC.
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:
1477796191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1114 BROAD STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-242-8088
Provider Business Mailing Address Fax Number:
973-242-8069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 BROAD ST # 1114
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07102-2660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-242-8088
Provider Business Practice Location Address Fax Number:
973-242-8069
Provider Enumeration Date:
04/10/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
RUBEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
973-477-7639

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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