Healthcare Provider Details

I. General information

NPI: 1427364488
Provider Name (Legal Business Name): REGIS F ACOSTA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 INDEPENDENCE BLVD
SICKLERVILLE NJ
08081-1039
US

IV. Provider business mailing address

104 INDEPENDENCE BLVD
SICKLERVILLE NJ
08081-1039
US

V. Phone/Fax

Practice location:
  • Phone: 856-885-4529
  • Fax:
Mailing address:
  • Phone: 856-885-4529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number25MA0732300
License Number StateNJ

VIII. Authorized Official

Name: REGIS F ACOSTA
Title or Position: OWNER
Credential: MD
Phone: 856-885-4529