Provider Demographics
NPI:1104315811
Name:PRIME
Entity type:Organization
Organization Name:PRIME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONA LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-936-2660
Mailing Address - Street 1:32 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-4869
Mailing Address - Country:US
Mailing Address - Phone:201-936-2660
Mailing Address - Fax:
Practice Address - Street 1:60 PARK PL STE 402
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-5513
Practice Address - Country:US
Practice Address - Phone:973-803-8130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ01062100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty