Healthcare Provider Details

I. General information

NPI: 1679909030
Provider Name (Legal Business Name): 21ST CENTURY TOTAL HEALTH CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 MAIN ST SUITE 101
ORANGE NJ
07050-1523
US

IV. Provider business mailing address

439 MAIN ST SUITE 101
ORANGE NJ
07050-1523
US

V. Phone/Fax

Practice location:
  • Phone: 973-675-8700
  • Fax: 973-675-8701
Mailing address:
  • Phone: 973-675-8700
  • Fax: 973-675-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number38MCOO641500
License Number StateNJ

VIII. Authorized Official

Name: KESNOLD BAPTISTE
Title or Position: PRESIDENT
Credential: DC
Phone: 908-625-7463