=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710318175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH JERSEY ELECTRODIAGNOSTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2013
-----------------------------------------------------
Last Update Date | 01/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1187 MAIN AVE STE 1D
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-2252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 473-788-8693
-----------------------------------------------------
Fax | 888-373-2114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7036
-----------------------------------------------------
City | WEST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07052-7036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-378-8869
-----------------------------------------------------
Fax | 888-373-2114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MARCO LOPEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-378-8869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204R00000X
-----------------------------------------------------
Taxonomy Name | Electrodiagnostic Medicine Physician
-----------------------------------------------------
License Number | 25MA07863200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------