Healthcare Provider Details

I. General information

NPI: 1659601789
Provider Name (Legal Business Name): DR JM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 ROUTE 70 EAST SUITE 1-C
BRICK NJ
08723-4022
US

IV. Provider business mailing address

525 ROUTE 70 EAST SUITE 1-C
BRICK NJ
08723-4022
US

V. Phone/Fax

Practice location:
  • Phone: 732-279-6537
  • Fax: 732-279-6542
Mailing address:
  • Phone: 732-279-6537
  • Fax: 732-279-6542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number25MA06682500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number25MA06682500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number25MA06682500
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number25MA06682500
License Number StateNJ

VIII. Authorized Official

Name: JERRY MABAGOS
Title or Position: OWNER
Credential:
Phone: 732-279-6537