# DOMINICK CONDO MD PA

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** MEDVANTX, INC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1770904138
- **Legal business name:** MEDVANTX, INC
- **Authorized official:** KENNY HEINE (VP OF OPERATIONS)
- **Authorized official phone:** (858) 964-1506

## Contact information

- **Practice address:** 622 BROADWAY, BAYONNE, NJ 07002-3821
- **Practice address phone:** (201) 436-2800
- **Mailing address:** 9276 SCRANTON RD, SUITE 100, SAN DIEGO, CA 92121-7701

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332900000X | Non-Pharmacy Dispensing Site | 25MA08097300 | NJ | Yes |

## Other

- **Enumeration date:** 01/02/2014
- **Last updated:** 12/10/2015