Provider Demographics
NPI:1184025595
Name:ESSENTIA HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:ESSENTIA HEALTH AND WELLNESS CENTER
Other - Org Name:ESSENTIAMD
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FLAVIA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:DE LA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-483-6800
Mailing Address - Street 1:48 VERBICKAS DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-3720
Mailing Address - Country:US
Mailing Address - Phone:973-483-6800
Mailing Address - Fax:973-776-1166
Practice Address - Street 1:587 WESTMINSTER AVE OFC
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2206
Practice Address - Country:US
Practice Address - Phone:973-483-6800
Practice Address - Fax:201-645-3787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08833900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0309826Medicaid