1013068568 NPI number — MR. CHARLES ROBERT HENDRICKS JR. P.T

Table of content: IRENE BASIL MASEVERIYO (NPI 1851865570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013068568 NPI number — MR. CHARLES ROBERT HENDRICKS JR. P.T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKS
Provider First Name:
CHARLES
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
P.T
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1013068568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 JESSICA PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONMOUTH BEACH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07750-1407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-625-2200
Provider Business Mailing Address Fax Number:
732-625-2205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 US HIGHWAY 9
Provider Second Line Business Practice Location Address:
SUITE 1500
Provider Business Practice Location Address City Name:
FREEHOLD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07728-1383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-625-2200
Provider Business Practice Location Address Fax Number:
732-625-2205
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  QA00767900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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