Healthcare Provider Details

I. General information

NPI: 1902476005
Provider Name (Legal Business Name): JOHN OBRIEN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 PASSAIC ST
PASSAIC NJ
07055-5814
US

IV. Provider business mailing address

333 PASSAIC ST
PASSAIC NJ
07055-5814
US

V. Phone/Fax

Practice location:
  • Phone: 973-365-5656
  • Fax: 973-365-5677
Mailing address:
  • Phone: 973-365-5656
  • Fax: 973-365-5677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number26NO09809300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: