Provider Demographics
NPI:1598969719
Name:FAMILY WALK-IN, LLC
Entity Type:Organization
Organization Name:FAMILY WALK-IN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DESTASIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-905-5255
Mailing Address - Street 1:4013 ROUTE 9 NORTH
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731
Mailing Address - Country:US
Mailing Address - Phone:732-905-5255
Mailing Address - Fax:732-905-5266
Practice Address - Street 1:4013 ROUTE 9 NORTH
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731
Practice Address - Country:US
Practice Address - Phone:732-905-5255
Practice Address - Fax:732-905-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX ID#