Provider Demographics
NPI:1528350568
Name:THE CENTER FOR MEDICAL WEIGHT LOSS OF BERGEN COUNTY,LLC
Entity type:Organization
Organization Name:THE CENTER FOR MEDICAL WEIGHT LOSS OF BERGEN COUNTY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-568-5936
Mailing Address - Street 1:363 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4104
Mailing Address - Country:US
Mailing Address - Phone:201-568-5936
Mailing Address - Fax:201-568-7567
Practice Address - Street 1:363 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4104
Practice Address - Country:US
Practice Address - Phone:201-568-5936
Practice Address - Fax:201-568-7567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02573000132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD19685Medicare UPIN