Healthcare Provider Details

I. General information

NPI: 1538520564
Provider Name (Legal Business Name): CENTRAL PAIN AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 SHEFFIELD DR
MOORESTOWN NJ
08057-3091
US

IV. Provider business mailing address

725 MILL ST
MOORESTOWN NJ
08057-1803
US

V. Phone/Fax

Practice location:
  • Phone: 856-255-5479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB06402900
License Number StateNJ

VIII. Authorized Official

Name: DR. GARY BUCK
Title or Position: OFFICER
Credential: MD
Phone: 856-255-5479