1174978159 NPI number — MR. MARK MELILLO MS, LCADC, RYT-200

Table of content: MR. MARK MELILLO MS, LCADC, RYT-200 (NPI 1174978159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174978159 NPI number — MR. MARK MELILLO MS, LCADC, RYT-200

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELILLO
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS, LCADC, RYT-200
Provider Gender Code:
M

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:
1174978159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 LINCOLN PL
Provider Second Line Business Mailing Address:
D
Provider Business Mailing Address City Name:
NORTH BRUNSWICK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08902-4014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-331-7796
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MONUMENT DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08540-4014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-924-8018
Provider Business Practice Location Address Fax Number:
609-688-2045
Provider Enumeration Date:
04/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  37LC00252200 , 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)

  • Identifier: 1174978159 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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