MEDICARE: THE POD SPA

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	302R00000X	Health Maintenance Organization	25MA03452100	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780085456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE POD SPA

Provider Business Mailing Address
First Line	:	7000 BOULEVARD EAST
Second Line	:
City	:	GUTTENBERG
State	:	NJ
Zip	:	07093-4818
Country	:	US
Telephone Number	:	201-988-7058
Fax Number	:

Provider Business Practice Location Address
First Line	:	9014 DURHAM AVE
Second Line	:	2ND FLOOR
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-4438
Country	:	US
Telephone Number	:	201-988-7058
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AMALIA DE MIER
Credential	:
Telephone Number	:	201-994-7028

Provider Enumeration Date	:	09/11/2014
Last Update Date	:	09/19/2014

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Directions to “THE POD SPA ” Practice Location

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