Healthcare Provider Details

I. General information

NPI: 1447905245
Provider Name (Legal Business Name): MRC WEST MEDSPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 BLOOMFIELD AVE
WEST CALDWELL NJ
07006-6701
US

IV. Provider business mailing address

761 BLOOMFIELD AVE
WEST CALDWELL NJ
07006-6701
US

V. Phone/Fax

Practice location:
  • Phone: 862-284-3747
  • Fax: 973-860-1602
Mailing address:
  • Phone: 862-284-3747
  • Fax: 973-860-1602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLY DISTEFANO
Title or Position: OWNER
Credential: MD
Phone: 862-216-9732