Healthcare Provider Details

I. General information

NPI: 1780417543
Provider Name (Legal Business Name): NICHOLAS MILEWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2-22 BANTA PL
FAIR LAWN NJ
07410-3058
US

IV. Provider business mailing address

2-22 BANTA PL
FAIR LAWN NJ
07410-3058
US

V. Phone/Fax

Practice location:
  • Phone: 201-509-8600
  • Fax:
Mailing address:
  • Phone: 201-509-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00333200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: