Healthcare Provider Details

I. General information

NPI: 1922150358
Provider Name (Legal Business Name): MONMOUTH ADVANCED MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 STILLWELLS CORNER RD
FREEHOLD NJ
07728
US

IV. Provider business mailing address

503 STILLWELLS CORNER RD
FREEHOLD NJ
07728
US

V. Phone/Fax

Practice location:
  • Phone: 732-308-0099
  • Fax: 732-308-0347
Mailing address:
  • Phone: 732-308-0099
  • Fax: 732-308-0347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00271700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number38MC00395200
License Number StateNJ

VIII. Authorized Official

Name: STEVEN MARC ZODKOY
Title or Position: OWNER
Credential: D.C.
Phone: 732-308-0099