1053818559 NPI number — CORINA M IANCULOVICI APRN, AG-PCP

Table of content: CORINA M IANCULOVICI APRN, AG-PCP (NPI 1053818559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053818559 NPI number — CORINA M IANCULOVICI APRN, AG-PCP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IANCULOVICI
Provider First Name:
CORINA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, AG-PCP
Provider Gender Code:
F

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:
1053818559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2640 HWY 70, BLDG.5
Provider Second Line Business Mailing Address:
BUILDING #5, SUITE 102B
Provider Business Mailing Address City Name:
MANASQUAN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08736-9552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-539-6369
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2640 HWY 70, BLDG.5
Provider Second Line Business Practice Location Address:
BUILDING #5, SUITE 102B
Provider Business Practice Location Address City Name:
MANASQUAN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08736-9552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-292-0100
Provider Business Practice Location Address Fax Number:
732-292-0900
Provider Enumeration Date:
04/11/2018

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: 363LG0600X , with the licence number:  26NJ00862000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: 26NJ00862000 , 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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