Provider Demographics
NPI:1619020518
Name:VALLEY CENTER FOR FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:VALLEY CENTER FOR FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCCINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-940-0512
Mailing Address - Street 1:14 VIOLET TRL
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:07848-2203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 VIOLET TRL
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:NJ
Practice Address - Zip Code:07848-2203
Practice Address - Country:US
Practice Address - Phone:973-940-0512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA035277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1163604Medicaid
NJ527880Medicare PIN
NJC55066Medicare UPIN