Healthcare Provider Details

I. General information

NPI: 1942698436
Provider Name (Legal Business Name): PAIN RELIEF CENTER OF SOUTH JERSEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GAITHER DRIVE.
MOUNT LAUREL NJ
08054
US

IV. Provider business mailing address

1 APPLE ORCHARD ROAD 1
MOORESTOWN NJ
08057
US

V. Phone/Fax

Practice location:
  • Phone: 856-722-7000
  • Fax: 866-202-7134
Mailing address:
  • Phone: 856-866-0711
  • Fax: 856-793-9050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GARY B BUCK
Title or Position: HEAD PHYSICIAN
Credential: MD/.RP.H.
Phone: 856-255-5479