Provider Demographics
NPI:1720344690
Name:SANTA MARIA CLINIC
Entity Type:Organization
Organization Name:SANTA MARIA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICIO
Authorized Official - Middle Name:JORGE
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-991-1129
Mailing Address - Street 1:845 KEARNY AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-3244
Mailing Address - Country:US
Mailing Address - Phone:201-991-1129
Mailing Address - Fax:201-991-2272
Practice Address - Street 1:845 KEARNY AVE
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-3244
Practice Address - Country:US
Practice Address - Phone:201-991-1129
Practice Address - Fax:201-991-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06334400261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
235585OtherMEDICARE PTAN
235585OtherMEDICARE PTAN