Healthcare Provider Details

I. General information

NPI: 1104590264
Provider Name (Legal Business Name): TIDES OF CHANGE WELLNESS COLLABORATIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 TILTON RD STE 4
NORTHFIELD NJ
08225-1857
US

IV. Provider business mailing address

302 ARLINGTON CT
EGG HARBOR TOWNSHIP NJ
08234-6012
US

V. Phone/Fax

Practice location:
  • Phone: 856-332-1151
  • Fax:
Mailing address:
  • Phone: 856-332-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LAUREN ASHLEY DAVIS
Title or Position: CO-OWNER / MEMBER
Credential: DO
Phone: 856-332-1151