Provider Demographics
NPI:1720168412
Name:EXECUTIVE MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:EXECUTIVE MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-845-6433
Mailing Address - Street 1:99 CHAMBERLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1411
Mailing Address - Country:US
Mailing Address - Phone:201-230-9594
Mailing Address - Fax:201-845-6435
Practice Address - Street 1:99 CHAMBERLAIN AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-1411
Practice Address - Country:US
Practice Address - Phone:201-230-9594
Practice Address - Fax:201-845-6435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile