Healthcare Provider Details

I. General information

NPI: 1811487911
Provider Name (Legal Business Name): IRON SPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 46TH ST APT 2
WEEHAWKEN NJ
07086-7168
US

IV. Provider business mailing address

65 46TH ST APT 2
WEEHAWKEN NJ
07086-7168
US

V. Phone/Fax

Practice location:
  • Phone: 310-463-1782
  • Fax:
Mailing address:
  • Phone: 310-463-1782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: WESLEY MICHAEL GOBER
Title or Position: FOUNDER
Credential:
Phone: 310-463-1782