Provider Demographics
NPI:1558526459
Name:MOUNTAIN LAKES INTEGRATED HEALTHCARE
Entity Type:Organization
Organization Name:MOUNTAIN LAKES INTEGRATED HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOLASEK
Authorized Official - Suffix:
Authorized Official - Credentials:D AC, L AC, C A
Authorized Official - Phone:973-331-0200
Mailing Address - Street 1:115 US HIGHWAY 46
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1668
Mailing Address - Country:US
Mailing Address - Phone:973-331-0200
Mailing Address - Fax:
Practice Address - Street 1:115 US HIGHWAY 46
Practice Address - Street 2:SUITE A-3
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1668
Practice Address - Country:US
Practice Address - Phone:973-331-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service