=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578988481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEIGHBORHOOD MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2014
-----------------------------------------------------
Last Update Date | 02/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 CENTRAL AVE SUITE 100
-----------------------------------------------------
City | EAST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07018-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-370-6452
-----------------------------------------------------
Fax | 973-674-8033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 CENTRAL AVE SUITE 100
-----------------------------------------------------
City | EAST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07018-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-370-6452
-----------------------------------------------------
Fax | 973-674-8033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MONICA MARIA CLARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-370-6452
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00416900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------