Healthcare Provider Details

I. General information

NPI: 1184391849
Provider Name (Legal Business Name): NJ INTEGRATED HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 KING GEORGE RD STE 205
BASKING RIDGE NJ
07920-2817
US

IV. Provider business mailing address

413 KING GEORGE RD STE 205
BASKING RIDGE NJ
07920-2817
US

V. Phone/Fax

Practice location:
  • Phone: 908-903-1901
  • Fax: 908-903-1902
Mailing address:
  • Phone: 908-903-1901
  • Fax: 908-903-1902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER CARROLL
Title or Position: OFFICE MANAGER
Credential:
Phone: 352-678-3092