Provider Demographics
NPI:1053732412
Name:NILSEN-REMEDIOS, MATTHEW (LAC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:NILSEN-REMEDIOS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W PASSAIC ST STE 8
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-1264
Mailing Address - Country:US
Mailing Address - Phone:201-343-2500
Mailing Address - Fax:201-343-2551
Practice Address - Street 1:240 W PASSAIC ST STE 8
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1264
Practice Address - Country:US
Practice Address - Phone:201-343-2500
Practice Address - Fax:201-343-2551
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00101200171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist