Healthcare Provider Details

I. General information

NPI: 1912909433
Provider Name (Legal Business Name): CENTENNIAL SURGUNIT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 CENTENNIAL BLVD SUITE 1
VOORHEES NJ
08043-9544
US

IV. Provider business mailing address

502 CENTENNIAL BLVD SUITE 1
VOORHEES NJ
08043-9544
US

V. Phone/Fax

Practice location:
  • Phone: 856-874-0790
  • Fax: 856-751-0349
Mailing address:
  • Phone: 856-874-0790
  • Fax: 856-751-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number22835
License Number StateNJ

VIII. Authorized Official

Name: MR. STEPHEN BARAINYAK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 856-874-0790