Healthcare Provider Details

I. General information

NPI: 1699226407
Provider Name (Legal Business Name): VINCENT BESAW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NJ-73
VOORHEES TOWNSHIP NJ
08043
US

IV. Provider business mailing address

37 UPTON WAY
SEWELL NJ
08080-3621
US

V. Phone/Fax

Practice location:
  • Phone: 856-809-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00752900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: