Healthcare Provider Details

I. General information

NPI: 1518310366
Provider Name (Legal Business Name): SKIN & LASER CENTER OF NJ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N FRANKLIN TPKE STE 318
RAMSEY NJ
07446-1160
US

IV. Provider business mailing address

500 N FRANKLIN TPKE STE 318
RAMSEY NJ
07446-1160
US

V. Phone/Fax

Practice location:
  • Phone: 201-500-7525
  • Fax: 201-500-7527
Mailing address:
  • Phone: 201-500-7525
  • Fax: 201-500-7527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA08780100
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JOCELYN LIEB
Title or Position: SOLE MEMBER
Credential: MD
Phone: 201-500-7525