Healthcare Provider Details

I. General information

NPI: 1962723544
Provider Name (Legal Business Name): GARDEN STATE PAIN AND RADIOLOGY CENTER 2, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 ROUTE 88 W SUITE 102
BRICK NJ
08724-3009
US

IV. Provider business mailing address

PO BOX 397
WHITING NJ
08759-0397
US

V. Phone/Fax

Practice location:
  • Phone: 732-849-0077
  • Fax:
Mailing address:
  • Phone: 732-849-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA06331000
License Number StateNJ

VIII. Authorized Official

Name: DR. SUNITA MANN
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 732-849-0077