Provider Demographics
NPI:1750101309
Name:MEDINA COMMUNITY CLINIC INC
Entity type:Organization
Organization Name:MEDINA COMMUNITY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SADEGHI
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:609-533-1918
Mailing Address - Street 1:3628 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-5922
Mailing Address - Country:US
Mailing Address - Phone:609-533-1918
Mailing Address - Fax:
Practice Address - Street 1:828 N OLDEN AVE STE 2
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-4902
Practice Address - Country:US
Practice Address - Phone:609-323-5159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty