Healthcare Provider Details

I. General information

NPI: 1750745519
Provider Name (Legal Business Name): CORIELL LIFE SCIENCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 05/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 HADDON AVE
CAMDEN NJ
08103-1505
US

IV. Provider business mailing address

403 HADDON AVE
CAMDEN NJ
08103-1505
US

V. Phone/Fax

Practice location:
  • Phone: 856-533-0484
  • Fax:
Mailing address:
  • Phone: 856-533-0484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number25MJ00008800
License Number StateNJ

VIII. Authorized Official

Name: DR. JEFFREY A SHAMAN
Title or Position: DIRECTOR
Credential:
Phone: 856-533-0484