Healthcare Provider Details

I. General information

NPI: 1841433729
Provider Name (Legal Business Name): A MEDICAL HOME FOR YOU LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 06/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 PROSPECT AVE
HACKENSACK NJ
07601-2506
US

IV. Provider business mailing address

1055 RIVER RD PO BOX 117
NEW MILFORD NJ
07646-3221
US

V. Phone/Fax

Practice location:
  • Phone: 206-424-9157
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07724400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ANDREW LAN
Title or Position: OWNER
Credential:
Phone: 206-424-9157