Provider Demographics
NPI:1003557224
Name:MINI MINE LLC
Entity type:Organization
Organization Name:MINI MINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALKA
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:732-886-8113
Mailing Address - Street 1:128 MELVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4235
Mailing Address - Country:US
Mailing Address - Phone:732-886-8113
Mailing Address - Fax:
Practice Address - Street 1:128 MELVILLE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4235
Practice Address - Country:US
Practice Address - Phone:732-886-8113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-03
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center