1063730620 NPI number — DANIELLE BRENZA, DO LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063730620 NPI number — DANIELLE BRENZA, DO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DANIELLE BRENZA, DO 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:
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:
1063730620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 BRIGGS RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
MOUNT LAUREL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08054-4100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-231-4774
Provider Business Mailing Address Fax Number:
856-231-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 OAKSHADE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAMONG
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08088-9520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-268-0699
Provider Business Practice Location Address Fax Number:
888-268-7603
Provider Enumeration Date:
05/06/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRENZA
Authorized Official First Name:
DANIELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
609-268-0699

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25MB07030800 , 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)