Provider Demographics
NPI:1912334434
Name:NEW JERSEY PEDIATRIC AND ADOLESCENT CARE, LLC
Entity Type:Organization
Organization Name:NEW JERSEY PEDIATRIC AND ADOLESCENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-276-1140
Mailing Address - Street 1:4 FOX HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9300
Mailing Address - Country:US
Mailing Address - Phone:973-276-1140
Mailing Address - Fax:
Practice Address - Street 1:1680 ROUTE 23
Practice Address - Street 2:SUITE 350
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7501
Practice Address - Country:US
Practice Address - Phone:973-521-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-29
Last Update Date:2013-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06235800261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care