Healthcare Provider Details

I. General information

NPI: 1851949341
Provider Name (Legal Business Name): SAMANTHA REPEKTA RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 GETTY AVENUE
PATERSON NJ
07503
US

IV. Provider business mailing address

235 OLD YORK RD
BRIDGEWATER NJ
08807-2618
US

V. Phone/Fax

Practice location:
  • Phone: 973-754-4302
  • Fax:
Mailing address:
  • Phone: 973-767-8498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86110160
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: