Provider Demographics
NPI:1215285440
Name:GILLISS FAMILY CARE,LLC
Entity type:Organization
Organization Name:GILLISS FAMILY CARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:GILLISS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-230-9282
Mailing Address - Street 1:27 E CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:MERCHANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-2504
Mailing Address - Country:US
Mailing Address - Phone:609-230-9282
Mailing Address - Fax:
Practice Address - Street 1:27 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:MERCHANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08109-2504
Practice Address - Country:US
Practice Address - Phone:609-230-9282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05998100261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service