Healthcare Provider Details

I. General information

NPI: 1528258191
Provider Name (Legal Business Name): 92 BRICK ROAD OPERATING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 BRICK RD
MARLTON NJ
08053-2177
US

IV. Provider business mailing address

92 BRICK RD
MARLTON NJ
08053-2177
US

V. Phone/Fax

Practice location:
  • Phone: 856-988-8778
  • Fax: 856-988-8254
Mailing address:
  • Phone: 856-988-4100
  • Fax: 609-261-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRAD E. HOLLINGER
Title or Position: PRESIDENT
Credential:
Phone: 717-591-5700