Healthcare Provider Details

I. General information

NPI: 1588009161
Provider Name (Legal Business Name): GCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MOUNT PROSPECT AVE SUITE 104
CLIFTON NJ
07013-1900
US

IV. Provider business mailing address

50 MOUNT PROSPECT AVE SUITE 104
CLIFTON NJ
07013-1900
US

V. Phone/Fax

Practice location:
  • Phone: 973-928-1325
  • Fax: 973-365-2371
Mailing address:
  • Phone: 973-928-1325
  • Fax: 973-365-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA08001500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number25MA08001500
License Number StateNJ

VIII. Authorized Official

Name: SEAN LAGER
Title or Position: OWNER
Credential: M.D.
Phone: 973-928-1325