Healthcare Provider Details

I. General information

NPI: 1669587267
Provider Name (Legal Business Name): WARREN SKIN CARE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 MEMORIAL PKWY BLDG 204
PHILLIPSBURG NJ
08865-2748
US

IV. Provider business mailing address

PO BOX 5118
PHILLIPSBURG NJ
08865-2748
US

V. Phone/Fax

Practice location:
  • Phone: 908-387-1001
  • Fax: 908-387-1195
Mailing address:
  • Phone: 908-387-1001
  • Fax: 908-387-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberMA66021
License Number StateNJ

VIII. Authorized Official

Name: LIAN JIE LI
Title or Position: CEO
Credential: MD
Phone: 908-387-1001