Healthcare Provider Details

I. General information

NPI: 1457682213
Provider Name (Legal Business Name): NIA MEDICAL CENTER AND SPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 MOUNT PROSPECT AVE
NEWARK NJ
07104-3228
US

IV. Provider business mailing address

851 MOUNT PROSPECT AVE
NEWARK NJ
07104-3228
US

V. Phone/Fax

Practice location:
  • Phone: 973-481-0501
  • Fax: 973-481-0503
Mailing address:
  • Phone: 973-481-0501
  • Fax: 973-481-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMA68696
License Number StateNJ

VIII. Authorized Official

Name: DR. NORMA B. MILANES ROBERTS
Title or Position: CHIEF OF OPERATIONS
Credential: MD
Phone: 973-481-0501