Healthcare Provider Details

I. General information

NPI: 1295080844
Provider Name (Legal Business Name): ATLANTIC INTEGRATIVE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E BLACK HORSE PIKE
PLEASANTVILLE NJ
08232-2737
US

IV. Provider business mailing address

201 E BLACK HORSE PIKE
PLEASANTVILLE NJ
08232-2737
US

V. Phone/Fax

Practice location:
  • Phone: 609-641-9009
  • Fax: 609-641-3918
Mailing address:
  • Phone: 609-641-9009
  • Fax: 609-641-3918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number25MA08838800
License Number StateNJ

VIII. Authorized Official

Name: PIA J GARDNER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 609-641-9009