Healthcare Provider Details

I. General information

NPI: 1104949528
Provider Name (Legal Business Name): SHORE SURGICAL ASSISTANT SERVICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 05/21/2020
Certification Date: 03/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 TUCKAHOE RD
DOROTHY NJ
08317-9702
US

IV. Provider business mailing address

PO BOX 331
MAYS LANDING NJ
08330-0331
US

V. Phone/Fax

Practice location:
  • Phone: 609-476-4624
  • Fax:
Mailing address:
  • Phone: 973-957-0551
  • Fax: 866-396-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number26NO09467800
License Number StateNJ

VIII. Authorized Official

Name: MR. GARY A BUCK
Title or Position: OWNER
Credential: CRNFA
Phone: 609-476-4624