Healthcare Provider Details

I. General information

NPI: 1730362153
Provider Name (Legal Business Name): NORTHERN VALLEY PAIN CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CLOSTER DOCK RD
CLOSTER NJ
07624-1928
US

IV. Provider business mailing address

200 CLOSTER DOCK RD
CLOSTER NJ
07624-1928
US

V. Phone/Fax

Practice location:
  • Phone: 877-877-6900
  • Fax:
Mailing address:
  • Phone: 877-877-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOELLEN GATELY
Title or Position: ACCT MANAGER
Credential:
Phone: 631-732-7426