1164967956 NPI number — ENGELWOOD DIAGNOSTIC & IMAGING CENTER LLC

Table of content: (NPI 1164967956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164967956 NPI number — ENGELWOOD DIAGNOSTIC & IMAGING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENGELWOOD DIAGNOSTIC & IMAGING CENTER 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:
1164967956
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
177 N DEAN ST
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07631-2533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-731-3507
Provider Business Mailing Address Fax Number:
201-731-3056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
177 N DEAN ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07631-2533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-731-3507
Provider Business Practice Location Address Fax Number:
800-394-6163
Provider Enumeration Date:
01/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LASMIN
Authorized Official First Name:
SONIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
201-874-9084

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  24402 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X , with the licence number: 24402 , 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)





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