1699346437 NPI number — PRECIDENT OF NEW JERSEY, LLC

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 1699346437 NPI number — PRECIDENT OF NEW JERSEY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRECIDENT OF NEW JERSEY, LLC
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:
1699346437
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2714
Provider Second Line Business Mailing Address:
DEPT 2243
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72033-2714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-256-0103
Provider Business Mailing Address Fax Number:
973-256-8066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135 BROAD ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLIFTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07013-3346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-256-0103
Provider Business Practice Location Address Fax Number:
973-256-8066
Provider Enumeration Date:
07/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BOLDING
Authorized Official First Name:
SCOTTY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-957-4611

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22DI02335600 . This is a "NJ STATE LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 22DI02335601 . This is a "NJ STATE LICENSE BRANCH OFFICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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