Healthcare Provider Details

I. General information

NPI: 1356431571
Provider Name (Legal Business Name): GARDEN STATE ALLERGY AND ASTHMA CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 CENTRE BOULEVARD SUITE B
MARLTON NJ
08053
US

IV. Provider business mailing address

102 CENTRE BOULEVARD SUITE B
MARLTON NJ
08053
US

V. Phone/Fax

Practice location:
  • Phone: 856-753-8989
  • Fax: 856-753-9588
Mailing address:
  • Phone: 856-753-8989
  • Fax: 856-753-9588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number25MA07514500
License Number StateNJ

VIII. Authorized Official

Name: DR. RICHARD A. WACHS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 856-417-6185