Provider Demographics
NPI:1821496712
Name:PPMD WEST BERLIN 1ST FLOOR
Entity Type:Organization
Organization Name:PPMD WEST BERLIN 1ST FLOOR
Other - Org Name:PROVIDENCE PEDIATRIC MEDICAL DAYCARE INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRECIDENT / CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN-LOZADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-753-7763
Mailing Address - Street 1:411 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:WEST BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08091-9254
Mailing Address - Country:US
Mailing Address - Phone:856-753-7763
Mailing Address - Fax:856-753-7714
Practice Address - Street 1:411 COMMERCE LN
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:WEST BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08091-9254
Practice Address - Country:US
Practice Address - Phone:856-753-7935
Practice Address - Fax:856-753-7714
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PEDIATRIC MEDICAL DAYCARE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ04012261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care