1174877757 NPI number — S.O.B HEALTH SYSTEM LLC

Table of content: (NPI 1174877757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174877757 NPI number — S.O.B HEALTH SYSTEM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S.O.B HEALTH SYSTEM 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:
6
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:
1174877757
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
335 E JIMMIE LEEDS RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
GALLOWAY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08205-4127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-573-5310
Provider Business Mailing Address Fax Number:
609-241-1922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 E JIMMIE LEEDS RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GALLOWAY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08205-4127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-573-5310
Provider Business Practice Location Address Fax Number:
609-241-1922
Provider Enumeration Date:
11/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BILEWU
Authorized Official First Name:
EBENEZER
Authorized Official Middle Name:
O-A
Authorized Official Title or Position:
CHIROPRACTIC PHYSICIAN
Authorized Official Telephone Number:
609-573-5310

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  38MC00702600 , 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)

  • Identifier: 3893359000 . This is a "AMERIHEALTH NEW JERSEY" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 389360000 . This is a "AMERIHEALTH NEW JERSEY" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 60114338 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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