Healthcare Provider Details

I. General information

NPI: 1326767500
Provider Name (Legal Business Name): CROWN & GLORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 CLINTON PL
HACKENSACK NJ
07601-3686
US

IV. Provider business mailing address

209 CLINTON PL
HACKENSACK NJ
07601-3686
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-4100
  • Fax:
Mailing address:
  • Phone: 201-487-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
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: MS. ANGELA PHIPPS
Title or Position: CERTIFIED HAIR LOSS SPECIALIST
Credential: CHLS
Phone: 201-487-4100