| Organization Name: | KENILWORTH PRIMARY CARE LLC |
| NPI Number: | 1164793014 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BHAVANI JEEREDDY (SOLE MEMBER) |
| Mailing Address: | 66 S 21st St Kenilworth |
| State: | NJ US |
| Postal Code: | 070331626 |
| Phone Number: | 9082769595 |
| Fax Number: | 9082766807 |
| NPI Enumeration Date: | 01/24/2012 |
| NPI Last Update Date: | 01/24/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NJ |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |