1124297130 NPI number — MR. CHARLES BARRYMORE GREENE II LCADC

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 1124297130 NPI number — MR. CHARLES BARRYMORE GREENE II LCADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
CHARLES
Provider Middle Name:
BARRYMORE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
II
Provider Credential Text:
LCADC
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:
1124297130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 COUNTRY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SICKLERVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08081-9312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-701-4731
Provider Business Mailing Address Fax Number:
856-757-0541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 S BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08103-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-757-9190
Provider Business Practice Location Address Fax Number:
856-338-1892
Provider Enumeration Date:
02/22/2008

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: 101YA0400X , with the licence number:  37LC00141700 , 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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