Healthcare Provider Details

I. General information

NPI: 1144464553
Provider Name (Legal Business Name): CHILDREN OF JOY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 SUMMIT AVENUE
HACKENSACK NJ
07601
US

IV. Provider business mailing address

582 PENN AVENUE
TEANECK NJ
07666
US

V. Phone/Fax

Practice location:
  • Phone: 201-525-0077
  • Fax: 201-525-0072
Mailing address:
  • Phone: 201-525-0077
  • Fax: 201-525-0072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07684400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA0768440
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0082368
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: MRS. MILDRED BENOIT
Title or Position: OFFICE MANAGER
Credential:
Phone: 201-525-0077