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General NPI Number Information
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NPI Number | 1609144005
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Entity Type | Organization
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Legal Business Name | ELITE PREMIER MEDICAL CARE LLC
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Dates
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Enumeration Date | 12/13/2011
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Last Update Date | 12/13/2011
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Provider Practice Location Address
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Address Line | 470 CHAMBERLAIN AVE STE 7
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City | PATERSON
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State | NJ
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Zip | 07522-1000
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Country | US
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Telephone | 973-595-7400
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Fax |
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Provider Business Mailing Address
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Address Line | 425 15TH AVE STE 2
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City | PATERSON
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State | NJ
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Zip | 07504-1811
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Country | US
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Telephone | 973-595-7400
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Fax | 973-345-4156
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Authorized Official
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Title or Position | GENERAL MANEGAR
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Name | MIRYAM REVOREDO
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Credential |
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Telephone | 973-595-7400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 25MA07147400
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License Number State | NJ
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