Provider Demographics
NPI:1619462124
Name:FOFANA, MUKHTAR
Entity Type:Individual
Prefix:MR
First Name:MUKHTAR
Middle Name:
Last Name:FOFANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 HEMPSTEAD DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-3948
Mailing Address - Country:US
Mailing Address - Phone:732-485-3959
Mailing Address - Fax:
Practice Address - Street 1:156 HEMPSTEAD DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-3948
Practice Address - Country:US
Practice Address - Phone:732-485-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness