Provider Demographics
NPI:1447905245
Name:MRC WEST MEDSPA LLC
Entity type:Organization
Organization Name:MRC WEST MEDSPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:862-216-9732
Mailing Address - Street 1:761 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-6701
Mailing Address - Country:US
Mailing Address - Phone:862-284-3747
Mailing Address - Fax:973-860-1602
Practice Address - Street 1:761 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-6701
Practice Address - Country:US
Practice Address - Phone:862-284-3747
Practice Address - Fax:973-860-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center