Provider Demographics
NPI:1881884369
Name:MOBILE MEDICAL OF MONTVILLE, LLC
Entity type:Organization
Organization Name:MOBILE MEDICAL OF MONTVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMINE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MAZZELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-886-9923
Mailing Address - Street 1:35 PALOMINO TRL
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:NJ
Mailing Address - Zip Code:07462-3143
Mailing Address - Country:US
Mailing Address - Phone:973-886-9923
Mailing Address - Fax:973-209-0246
Practice Address - Street 1:35 PALOMINO TRL
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:NJ
Practice Address - Zip Code:07462-3143
Practice Address - Country:US
Practice Address - Phone:973-886-9923
Practice Address - Fax:973-209-0246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMBO60952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty