Healthcare Provider Details

I. General information

NPI: 1114195500
Provider Name (Legal Business Name): DEMRECA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 51ST ST
AVALON NJ
08202-1310
US

IV. Provider business mailing address

261 51ST ST
AVALON NJ
08202-1310
US

V. Phone/Fax

Practice location:
  • Phone: 609-624-8986
  • Fax: 609-624-9098
Mailing address:
  • Phone: 609-624-8986
  • Fax: 609-624-9098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. THOMAS DIERKES
Title or Position: PRESIDENT
Credential: D.O.
Phone: 609-624-8986