1902104573 NPI number — JERSEY CITY RADIATION THERAPY LLC

Table of content: KRISTEN MARIE PENATE LCSW (NPI 1629523295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902104573 NPI number — JERSEY CITY RADIATION THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERSEY CITY RADIATION THERAPY 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:
1902104573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
631 GRAND STREET
Provider Second Line Business Mailing Address:
SUITE 1-1
Provider Business Mailing Address City Name:
JERSEY CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-791-4544
Provider Business Mailing Address Fax Number:
201-794-6970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
631 GRAND STREET
Provider Second Line Business Practice Location Address:
SUITE 1-1
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-791-4544
Provider Business Practice Location Address Fax Number:
201-794-6970
Provider Enumeration Date:
03/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VARDARO
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
201-791-4544

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  0400329589 , 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)





Copyright © 2007-2025 www.npivalidator.com