Healthcare Provider Details

I. General information

NPI: 1457612509
Provider Name (Legal Business Name): CHANIE KOPLOWITZ RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 BROOK AVE
PASSAIC NJ
07055-3314
US

IV. Provider business mailing address

290 BROOK AVE
PASSAIC NJ
07055-3314
US

V. Phone/Fax

Practice location:
  • Phone: 973-574-8736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number891928
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: