Healthcare Provider Details

I. General information

NPI: 1144583519
Provider Name (Legal Business Name): ST REMI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 KLEMM AVE
GLOUCESTER CITY NJ
08030-1627
US

IV. Provider business mailing address

822 KLEMM AVE
GLOUCESTER CITY NJ
08030-1627
US

V. Phone/Fax

Practice location:
  • Phone: 856-282-5566
  • Fax: 856-396-9917
Mailing address:
  • Phone: 856-282-5566
  • Fax: 856-885-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberMA072697
License Number StateNJ

VIII. Authorized Official

Name: ISIAKA A BOLARINWA
Title or Position: PRESIDENT/ MEDICAL DIRECTOR
Credential:
Phone: 856-282-5566