Healthcare Provider Details

I. General information

NPI: 1437229135
Provider Name (Legal Business Name): COUNTY LINE ENDOSCOPY & SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9226 KENNEDY BLVD UNIT A
NORTH BERGEN NJ
07047
US

IV. Provider business mailing address

9226 KENNEDY BLVD UNIT A
NORTH BERGEN NJ
07047
US

V. Phone/Fax

Practice location:
  • Phone: 201-295-0900
  • Fax: 201-869-9501
Mailing address:
  • Phone: 201-295-0900
  • Fax: 201-869-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIA P LUGO
Title or Position: OFFICE MGR
Credential:
Phone: 201-295-0900