Healthcare Provider Details

I. General information

NPI: 1013865211
Provider Name (Legal Business Name): CANNAGASM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2026
Last Update Date: 03/21/2026
Certification Date: 03/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 VALLEY RUN DR
CHERRY HILL NJ
08002-2404
US

IV. Provider business mailing address

314 VALLEY RUN DR
CHERRY HILL NJ
08002-2404
US

V. Phone/Fax

Practice location:
  • Phone: 856-883-7723
  • Fax:
Mailing address:
  • Phone: 856-883-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: NIGER ALI
Title or Position: CFO
Credential: BCHHP
Phone: 856-883-7723