Healthcare Provider Details

I. General information

NPI: 1932507183
Provider Name (Legal Business Name): ATLANTIC AGE MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MANCHESTER AVE
FORKED RIVER NJ
08731-1366
US

IV. Provider business mailing address

34 MANCHESTER AVE
FORKED RIVER NJ
08731-1366
US

V. Phone/Fax

Practice location:
  • Phone: 609-489-4648
  • Fax:
Mailing address:
  • Phone: 609-489-4648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMA 51879
License Number StateNJ

VIII. Authorized Official

Name: DR. GEORGE TRIM
Title or Position: PRESIDENT
Credential: MD
Phone: 609-489-4648