Healthcare Provider Details

I. General information

NPI: 1881772028
Provider Name (Legal Business Name): CANDLELIGHTING MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 CENTRAL AVE SUITE:1
EAST ORANGE NJ
07018-2529
US

IV. Provider business mailing address

404 CENTRAL AVENUE SUITE:1
EAST ORANGE NJ
07017
US

V. Phone/Fax

Practice location:
  • Phone: 973-414-8865
  • Fax: 973-672-2608
Mailing address:
  • Phone: 973-414-8865
  • Fax: 973-672-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number25MA06081600
License Number StateNJ

VIII. Authorized Official

Name: MS. JACKIE KINNEY
Title or Position: DIRECTOR OF CANDLELIGHT
Credential:
Phone: 973-414-8865