Healthcare Provider Details

I. General information

NPI: 1427363951
Provider Name (Legal Business Name): EAST COAST AESTHETIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PROSPECT AVE
HACKENSACK NJ
07601-2233
US

IV. Provider business mailing address

125 PROSPECT AVE
HACKENSACK NJ
07601-2233
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-7577
  • Fax: 201-488-1807
Mailing address:
  • Phone: 201-488-7577
  • Fax: 201-488-1807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ROBERT J MORIN
Title or Position: PRESIDENT
Credential: MD
Phone: 201-488-7577