Healthcare Provider Details

I. General information

NPI: 1003261934
Provider Name (Legal Business Name): LRX OF SOUTH JERSEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ROUTE 73 N SUITE E
MARLTON NJ
08053-1282
US

IV. Provider business mailing address

801 ROUTE 73 N SUITE E
MARLTON NJ
08053-1282
US

V. Phone/Fax

Practice location:
  • Phone: 856-348-3600
  • Fax: 856-348-3602
Mailing address:
  • Phone: 856-348-3600
  • Fax: 856-348-3602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. STEPHEN PEARSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 856-348-3600