1174998660 NPI number — SAGE NUTRITION AND HEALING CENTER CORPORATION

Table of content: (NPI 1174998660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174998660 NPI number — SAGE NUTRITION AND HEALING CENTER CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGE NUTRITION AND HEALING CENTER CORPORATION
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:
SAGE NUTRITION AND HEALING CENTER
Provider Other Organization Name Type Code:
3
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:
1174998660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
242 STATE ROUTE 79 N STE 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07751-2079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-443-0300
Provider Business Mailing Address Fax Number:
732-526-4150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
242 STATE ROUTE 79 N STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANVILLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07751-2079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-443-0300
Provider Business Practice Location Address Fax Number:
732-526-4150
Provider Enumeration Date:
12/09/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CORDIE
Authorized Official First Name:
TASMIN
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
324-443-0300

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  6626 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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