1972782704 NPI number — CENTER FOR NEUROLOGIC SPECIALTY

Table of content: (NPI 1972782704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972782704 NPI number — CENTER FOR NEUROLOGIC SPECIALTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR NEUROLOGIC SPECIALTY
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:
1972782704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53 NORMANDY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARLTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08053-5527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-988-3444
Provider Business Mailing Address Fax Number:
856-988-0553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12000 LINCOLN DR W
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
MARLTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08053-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-988-3444
Provider Business Practice Location Address Fax Number:
856-988-0553
Provider Enumeration Date:
10/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MABANTA
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
856-988-3444

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  MA59597 , 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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