1720247091 NPI number — PROVIDENCE PEDIATRIC MEDICAL DAYCARE, INC.

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 1720247091 NPI number — PROVIDENCE PEDIATRIC MEDICAL DAYCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE PEDIATRIC MEDICAL DAYCARE, INC.
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:
1720247091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 COMMERCE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BERLIN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08091-9254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-753-7763
Provider Business Mailing Address Fax Number:
856-753-7714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 S ANNAPOLIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTIC CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08401-5927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-345-2340
Provider Business Practice Location Address Fax Number:
609-345-3021
Provider Enumeration Date:
06/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROMAN
Authorized Official First Name:
LEEANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
856-753-7763

Provider Taxonomy Codes

  • Taxonomy code: 261QM3000X , with the licence number:  018200 , 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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