Healthcare Provider Details

I. General information

NPI: 1497069314
Provider Name (Legal Business Name): FAMILY PRACTICE CENTER, CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 51ST ST
WEST NEW YORK NJ
07093-5503
US

IV. Provider business mailing address

504 51ST ST
WEST NEW YORK NJ
07093-5503
US

V. Phone/Fax

Practice location:
  • Phone: 201-863-8342
  • Fax: 201-863-8415
Mailing address:
  • Phone: 201-863-8342
  • Fax: 201-863-8415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA03535900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25MA03535900
License Number StateNJ

VIII. Authorized Official

Name: DR. FERMIN J LEON
Title or Position: OWNER
Credential: M.D.
Phone: 201-863-8342