MEDICARE: SRC PENDING CONSULT MANAGEMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	26NR09534400	NJ

General Provider Information

NPI Number	:	1366433534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SRC PENDING CONSULT MANAGEMENT

Provider Business Mailing Address
First Line	:	1312 PARIS CT
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-3724
Country	:	US
Telephone Number	:	732-267-7737
Fax Number	:

Provider Business Practice Location Address
First Line	:	5250 MARYLAND AVE
Second Line	:
City	:	FORT DIX
State	:	NJ
Zip	:	08640-5058
Country	:	US
Telephone Number	:	609-562-6312
Fax Number	:

Authorized Official
Title or Position	:	CASE MANAGER
Name	:	MS. CHRISTALA CHERRY
Credential	:	RN, BSN
Telephone Number	:	609-562-6312

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	08/22/2020

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