Provider Demographics
NPI:1457796930
Name:GALLOWAY PEDIATRIC MEDICAL DAY CARE LLC
Entity Type:Organization
Organization Name:GALLOWAY PEDIATRIC MEDICAL DAY CARE LLC
Other - Org Name:PEDIATRIC DAY HEALTH CENTER AT GALLOWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:EHRENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-755-4047
Mailing Address - Street 1:2 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1217
Mailing Address - Country:US
Mailing Address - Phone:718-755-4047
Mailing Address - Fax:
Practice Address - Street 1:66 WEST JIMMIE LEEDS ROAD
Practice Address - Street 2:
Practice Address - City:ABSECON
Practice Address - State:NJ
Practice Address - Zip Code:08201
Practice Address - Country:US
Practice Address - Phone:609-748-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ018252261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ018252OtherLICENSE