MEDICARE: MRC WEST MEDSPA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1447905245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MRC WEST MEDSPA LLC

Provider Business Mailing Address
First Line	:	761 BLOOMFIELD AVE
Second Line	:
City	:	WEST CALDWELL
State	:	NJ
Zip	:	07006-6701
Country	:	US
Telephone Number	:	862-284-3747
Fax Number	:	973-860-1602

Provider Business Practice Location Address
First Line	:	761 BLOOMFIELD AVE
Second Line	:
City	:	WEST CALDWELL
State	:	NJ
Zip	:	07006-6701
Country	:	US
Telephone Number	:	862-284-3747
Fax Number	:	973-860-1602

Authorized Official
Title or Position	:	OWNER
Name	:	KELLY DISTEFANO
Credential	:	MD
Telephone Number	:	862-216-9732

Provider Enumeration Date	:	02/21/2022
Last Update Date	:	02/21/2022

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