1366693145 NPI number — ENGLEWOOD FAMILY HEALTH CENTER, P.A

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366693145 NPI number — ENGLEWOOD FAMILY HEALTH CENTER, P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENGLEWOOD FAMILY HEALTH CENTER, P.A
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:
1366693145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 ENGLE STREET, SUITE NUMBER 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07631-2581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-569-1530
Provider Business Mailing Address Fax Number:
201-569-6022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 ENGLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07631-2581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-569-1530
Provider Business Practice Location Address Fax Number:
201-569-6022
Provider Enumeration Date:
10/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PORTILLA
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
201-926-1828

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0611859 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: G11493 . This is a "UPIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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