Provider Demographics
NPI:1689845992
Name:J & J MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:J & J MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANNAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIEVES
Authorized Official - Middle Name:D
Authorized Official - Last Name:TIMIRAOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMEPOS
Authorized Official - Phone:973-553-2405
Mailing Address - Street 1:250 5TH AVE
Mailing Address - Street 2:1RS FLOOR
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07524-1818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:669 BROADWAY
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1947
Practice Address - Country:US
Practice Address - Phone:973-553-2405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1226387332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ460160OtherWELLCARE
NJ0213942Medicaid
NJ0213942Medicaid
NJ=========OtherAETNA
NJ5725420002Medicare NSC