Provider Demographics
NPI:1053412585
Name:LA NUEVA MERCEDES INC.
Entity type:Organization
Organization Name:LA NUEVA MERCEDES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLER/MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-279-2800
Mailing Address - Street 1:500 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07524-1903
Mailing Address - Country:US
Mailing Address - Phone:973-279-2800
Mailing Address - Fax:
Practice Address - Street 1:500 RIVER ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07524-1903
Practice Address - Country:US
Practice Address - Phone:973-279-2800
Practice Address - Fax:973-279-2197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS003284003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2821907Medicaid
NJ3863590001Medicare NSC