Healthcare Provider Details

I. General information

NPI: 1235375643
Provider Name (Legal Business Name): IN HER IMAGE- WEST CALDWELL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 PASSAIC AVE
WEST CALDWELL NJ
07006-7475
US

IV. Provider business mailing address

741 NORTHFIELD AVE SUITE 205
WEST ORANGE NJ
07052-1174
US

V. Phone/Fax

Practice location:
  • Phone: 973-467-9631
  • Fax: 973-530-3554
Mailing address:
  • Phone: 973-467-9631
  • Fax: 973-530-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD LEVINSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 201-247-3927