Provider Demographics
NPI:1073652210
Name:SALUS MED PC
Entity Type:Organization
Organization Name:SALUS MED PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:MANZANO
Authorized Official - Last Name:VILLONGCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:732-329-1257
Mailing Address - Street 1:7 TANNER DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-9488
Mailing Address - Country:US
Mailing Address - Phone:732-329-1257
Mailing Address - Fax:
Practice Address - Street 1:121 CEDAR LN
Practice Address - Street 2:SUITE2B
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4457
Practice Address - Country:US
Practice Address - Phone:732-485-6874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07738300207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01722150Medicaid
NY01722150Medicaid