Provider Demographics
NPI:1912768847
Name:EXCELSIA NJ, LLC
Entity Type:Organization
Organization Name:EXCELSIA NJ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:412-496-9559
Mailing Address - Street 1:9601 PULASKI PARK DR STE 417
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1409
Mailing Address - Country:US
Mailing Address - Phone:410-933-5678
Mailing Address - Fax:
Practice Address - Street 1:1937 BERLIN RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-3737
Practice Address - Country:US
Practice Address - Phone:856-616-0610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty