=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780931188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIORITY HEALTH AND WELLNESS CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2012
-----------------------------------------------------
Last Update Date | 08/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 930 VALLEY RD
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-696-3868
-----------------------------------------------------
Fax | 800-507-4594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 VALLEY RD
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-696-3868
-----------------------------------------------------
Fax | 800-507-4594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANTONIO ANGELITO
-----------------------------------------------------
Credential | DNP, APN,C
-----------------------------------------------------
Telephone | 973-696-3868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | 0400492155
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 0400492155
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------