Provider Demographics
NPI:1760058853
Name:PRECIOUS LIFE MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:PRECIOUS LIFE MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARDOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:RANA
Authorized Official - Suffix:
Authorized Official - Credentials:MSC, RDMS
Authorized Official - Phone:732-444-4646
Mailing Address - Street 1:1030 SAINT GEORGES AVE STE 200A
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1330
Mailing Address - Country:US
Mailing Address - Phone:732-444-4646
Mailing Address - Fax:
Practice Address - Street 1:1030 SAINT GEORGES AVE STE 200A
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1330
Practice Address - Country:US
Practice Address - Phone:732-444-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-31
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0886432Medicaid