Provider Demographics
NPI:1295245363
Name:NJ HOLISTIC WELLNESS CENTER LLC
Entity type:Organization
Organization Name:NJ HOLISTIC WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-981-0080
Mailing Address - Street 1:31-00 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3963
Mailing Address - Country:US
Mailing Address - Phone:201-746-5329
Mailing Address - Fax:
Practice Address - Street 1:31-00 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:201-746-5329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00115100171100000X
NJ25MZ00112100171100000X
NJ25MZ00096700171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MZ00115100OtherSTATE LICENSE
NJ25MZ00112100OtherSTATE LICENSE
1679810238OtherNPI
1801140942OtherNPI
1225384548OtherNPI
NJ25MZ00096700OtherSTATE LICENSE