1245665710 NPI number — HEALTH AND WELLNESS CENTER OF DOVER LLC

Table of content: (NPI 1245665710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245665710 NPI number — HEALTH AND WELLNESS CENTER OF DOVER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH AND WELLNESS CENTER OF DOVER 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:
1245665710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25-27 E DICKERSON ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07801-4655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-361-0750
Provider Business Mailing Address Fax Number:
973-343-7717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25-27 E DICKERSON ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07801-4655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-967-8425
Provider Business Practice Location Address Fax Number:
201-256-4665
Provider Enumeration Date:
09/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALES
Authorized Official First Name:
GUSTAVO
Authorized Official Middle Name:
Authorized Official Title or Position:
MSN, NP-C, CCRN
Authorized Official Telephone Number:
973-361-0750

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  26NJ00106400 , 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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