Provider Demographics
NPI:1558752410
Name:NJ WELLNESS CENTER PC
Entity Type:Organization
Organization Name:NJ WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALKER ROSARIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-495-8808
Mailing Address - Street 1:96 LINWOOD PLZ
Mailing Address - Street 2:RT 9 WEST STE 303
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-3701
Mailing Address - Country:US
Mailing Address - Phone:973-495-8808
Mailing Address - Fax:201-625-6699
Practice Address - Street 1:596 ANDERSON AVE STE 305
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-1888
Practice Address - Country:US
Practice Address - Phone:973-619-9694
Practice Address - Fax:201-625-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06845300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6519903Medicaid
NJG86605Medicare UPIN
NJ6519903Medicaid
G03995Medicare UPIN
363366Medicare PIN