Healthcare Provider Details

I. General information

NPI: 1952135964
Provider Name (Legal Business Name): SOUTH JERSEY WELLNESS SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N WOODBURY RD
PITMAN NJ
08071-1261
US

IV. Provider business mailing address

110 N WOODBURY RD
PITMAN NJ
08071-1261
US

V. Phone/Fax

Practice location:
  • Phone: 856-498-1243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK KIKER
Title or Position: PRINCIPAL
Credential:
Phone: 856-498-1243