Healthcare Provider Details

I. General information

NPI: 1245714443
Provider Name (Legal Business Name): LIFE ENHANCEMENT CENTER OF NORTH JERSEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 EAGLE ROCK AVE STE 4
WEST ORANGE NJ
07052-2138
US

IV. Provider business mailing address

18 ASPEN DR
LIVINGSTON NJ
07039-1432
US

V. Phone/Fax

Practice location:
  • Phone: 888-284-2034
  • Fax:
Mailing address:
  • Phone: 888-284-2034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEITH GOLIN
Title or Position: CEO
Credential: PHD
Phone: 888-284-2034