Provider Demographics
NPI:1366995896
Name:PASSAIC MEDICAL WALK-IN AND WELLNESS CENTER LLC
Entity type:Organization
Organization Name:PASSAIC MEDICAL WALK-IN AND WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-429-7165
Mailing Address - Street 1:916 MAIN AVE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-8545
Mailing Address - Country:US
Mailing Address - Phone:732-429-7165
Mailing Address - Fax:
Practice Address - Street 1:916 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-8545
Practice Address - Country:US
Practice Address - Phone:732-429-7165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care