Provider Demographics
NPI:1134319692
Name:NEW JERSEY MEDICAL SUPPLIES, LLC
Entity Type:Organization
Organization Name:NEW JERSEY MEDICAL SUPPLIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:DOMINGUEZ-YOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-778-3707
Mailing Address - Street 1:3111 ROUTE 38
Mailing Address - Street 2:LARCHMONT COMMONS BLDG 8
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-9754
Mailing Address - Country:US
Mailing Address - Phone:856-778-3707
Mailing Address - Fax:
Practice Address - Street 1:3111 ROUTE 38
Practice Address - Street 2:LARCHMONT COMMONS BLDG 8
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-9754
Practice Address - Country:US
Practice Address - Phone:856-778-3707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1362148332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6033060001Medicare NSC