Healthcare Provider Details

I. General information

NPI: 1982967758
Provider Name (Legal Business Name): TOTAL HEALTHCARE OF HAWTHORNE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 LAFAYETTE AVE
HAWTHORNE NJ
07506-1904
US

IV. Provider business mailing address

PO BOX 4157
RIVER EDGE NJ
07661-4157
US

V. Phone/Fax

Practice location:
  • Phone: 201-543-9992
  • Fax:
Mailing address:
  • Phone: 201-543-9992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07806100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS FREDY LUNA
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 201-543-9992