Provider Demographics
NPI:1407424021
Name:YOUR NEIGHBORHOOD CLINIC LLC
Entity Type:Organization
Organization Name:YOUR NEIGHBORHOOD CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUSANYA
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:908-312-0288
Mailing Address - Street 1:454 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1158
Mailing Address - Country:US
Mailing Address - Phone:908-312-0288
Mailing Address - Fax:
Practice Address - Street 1:454 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1158
Practice Address - Country:US
Practice Address - Phone:908-312-0288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care