Provider Demographics
NPI:1588824262
Name:LASER SKIN THERAPIES AT NOTCHVIEW-PINE BROOK, LLC
Entity Type:Organization
Organization Name:LASER SKIN THERAPIES AT NOTCHVIEW-PINE BROOK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDITERRANEO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-227-0169
Mailing Address - Street 1:18 HOOK MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9798
Mailing Address - Country:US
Mailing Address - Phone:973-227-0169
Mailing Address - Fax:973-227-8942
Practice Address - Street 1:1033 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2473
Practice Address - Country:US
Practice Address - Phone:973-779-3911
Practice Address - Fax:973-471-2730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05503100261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty