Healthcare Provider Details

I. General information

NPI: 1306112164
Provider Name (Legal Business Name): TOLENTINO MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HAMBURG TPKE SUITE 108
WAYNE NJ
07470-2154
US

IV. Provider business mailing address

25 HIDEAWAY LANE
SPARTA NJ
07871
US

V. Phone/Fax

Practice location:
  • Phone: 973-904-9553
  • Fax: 973-904-9274
Mailing address:
  • Phone: 862-377-4088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number0400459279
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0400459279
License Number StateNJ

VIII. Authorized Official

Name: DR. ELVIRA P. TOLENTINO
Title or Position: OWNER
Credential: M.D.
Phone: 862-377-4088