1912334434 NPI number — NEW JERSEY PEDIATRIC AND ADOLESCENT CARE, LLC

Table of content: (NPI 1912334434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912334434 NPI number — NEW JERSEY PEDIATRIC AND ADOLESCENT CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW JERSEY PEDIATRIC AND ADOLESCENT CARE, 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:
1912334434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 FOX HOLLOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07045-9300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-276-1140
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1680 ROUTE 23
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
WAYNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07470-7501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-521-9700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CHARLES
Authorized Official First Name:
LYDIA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
973-276-1140

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  25MA06235800 , 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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