Healthcare Provider Details

I. General information

NPI: 1043633381
Provider Name (Legal Business Name): GLTR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 MORRIS AVE SUITE A107
UNION NJ
07083-5714
US

IV. Provider business mailing address

2333 MORRIS AVE SUITE A107
UNION NJ
07083-5714
US

V. Phone/Fax

Practice location:
  • Phone: 201-634-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS P RAGUKONIS
Title or Position: AUTHORIZED REPRESENTATIVE
Credential: M.D.
Phone: 201-986-1003