1235523184 NPI number — GROSVENOR PARK HEALTH CENTER, 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 1235523184 NPI number — GROSVENOR PARK HEALTH CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROSVENOR PARK HEALTH CENTER, 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:
1235523184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2363 LAKEWOOD RD
Provider Second Line Business Mailing Address:
FLOOR 2
Provider Business Mailing Address City Name:
TOMS RIVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08755-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-710-4431
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 LORING HILLS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01970-4267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-741-5700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FISCH
Authorized Official First Name:
ELI
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF VENDOR RELATIONS
Authorized Official Telephone Number:
732-710-4431

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0968 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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