Healthcare Provider Details

I. General information

NPI: 1497972129
Provider Name (Legal Business Name): KENN TREIDEL RP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E ST
SEASIDE PARK NJ
08752-1512
US

IV. Provider business mailing address

117 E ST
SEASIDE PARK NJ
08752-1512
US

V. Phone/Fax

Practice location:
  • Phone: 732-854-7275
  • Fax:
Mailing address:
  • Phone: 732-854-7275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: