Provider Demographics
NPI:1851871370
Name:MILLAN, MARIO JR (HEALTH ADULT DAYCARE)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:JR
Last Name:MILLAN
Suffix:
Gender:M
Credentials:HEALTH ADULT DAYCARE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109
Mailing Address - Country:US
Mailing Address - Phone:973-336-4968
Mailing Address - Fax:973-751-7704
Practice Address - Street 1:114 WASHINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109
Practice Address - Country:US
Practice Address - Phone:973-429-0525
Practice Address - Fax:973-751-7704
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ831417720Medicaid