1346595089 NPI number — ESSENTIAL FOOT CARE PC

Table of content: (NPI 1346595089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346595089 NPI number — ESSENTIAL FOOT CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESSENTIAL FOOT CARE PC
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:
1346595089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 BERLIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEMENTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08021-4546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-783-0039
Provider Business Mailing Address Fax Number:
856-783-2312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 BERLIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEMENTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08021-4546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-747-7748
Provider Business Practice Location Address Fax Number:
856-783-2312
Provider Enumeration Date:
07/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ADELEKE
Authorized Official First Name:
OLUKOLA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
856-783-0039

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  25MD00313500 , 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: 0315486 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1027606800001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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