1780087312 NPI number — NORTH JERSEY VASCULAR CENTER LLC

Table of content: KATHERINE PETTY LCSW (NPI 1518706993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780087312 NPI number — NORTH JERSEY VASCULAR CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH JERSEY VASCULAR CENTER 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:
1780087312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
246 HAMBURG TPKE
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
WAYNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07470-2156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-653-3366
Provider Business Mailing Address Fax Number:
973-474-1031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1429 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLIFTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07013-4221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-653-3366
Provider Business Practice Location Address Fax Number:
973-474-1031
Provider Enumeration Date:
09/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MOQUETE
Authorized Official First Name:
MANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
973-653-3366

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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