Healthcare Provider Details

I. General information

NPI: 1871082933
Provider Name (Legal Business Name): VIKTORIIA KOBLIUK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922
US

IV. Provider business mailing address

166 MAPLE RD
WEST MILFORD NJ
07480-2704
US

V. Phone/Fax

Practice location:
  • Phone: 908-277-8679
  • Fax: 908-277-8909
Mailing address:
  • Phone: 917-704-7041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00818800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: