Healthcare Provider Details

I. General information

NPI: 1639561558
Provider Name (Legal Business Name): TARA VEGA CASTRO LI.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 ROUTE 168 STE 104
TURNERSVILLE NJ
08012-3224
US

IV. Provider business mailing address

860 ROUTE 168 STE 104
TURNERSVILLE NJ
08012-3224
US

V. Phone/Fax

Practice location:
  • Phone: 609-929-9343
  • Fax: 856-401-9551
Mailing address:
  • Phone: 609-929-9343
  • Fax: 856-401-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00110000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: