Provider Demographics
NPI:1700610094
Name:SENIOR DOC NEW JERSEY PC
Entity type:Organization
Organization Name:SENIOR DOC NEW JERSEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-702-5145
Mailing Address - Street 1:5 HUTTON CENTRE DR STE 950
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-8714
Mailing Address - Country:US
Mailing Address - Phone:714-702-5145
Mailing Address - Fax:949-281-5550
Practice Address - Street 1:5 HUTTON CENTRE DR STE 950
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-8714
Practice Address - Country:US
Practice Address - Phone:714-702-5145
Practice Address - Fax:949-281-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty