1518310366 NPI number — SKIN & LASER CENTER OF NJ, LLC

Table of content: PREIONA MARY SASAY KLINGENSMITH (NPI 1245793298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518310366 NPI number — SKIN & LASER CENTER OF NJ, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKIN & LASER CENTER OF NJ, 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:
1518310366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 N FRANKLIN TPKE STE 318
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAMSEY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07446-1160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-500-7525
Provider Business Mailing Address Fax Number:
201-500-7527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 N FRANKLIN TPKE STE 318
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAMSEY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07446-1160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-500-7525
Provider Business Practice Location Address Fax Number:
201-500-7527
Provider Enumeration Date:
07/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LIEB
Authorized Official First Name:
JOCELYN
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
201-500-7525

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  25MA08780100 , 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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