1063947828 NPI number — THERACORP, LLC

Table of content: (NPI 1063947828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063947828 NPI number — THERACORP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERACORP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THERACORP THERAPEUTIC SOLUTIONS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063947828
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
79 E RAILROAD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMESBURG
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08831-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-561-8555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79 E RAILROAD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESBURG
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08831-1207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-561-8555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
KRUTYANSKY
Authorized Official First Name:
ALLA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
973-207-6834

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  101Y00000X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 101YA0400X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 104200000X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 101YM0800X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 103T00000X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP0016X , with the licence number: 103TP0016X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP2701X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 1041X0700X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: 106H00000X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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