Healthcare Provider Details

I. General information

NPI: 1912196908
Provider Name (Legal Business Name): NORTHERN JERSEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

797 THOMAS LN
COLUMBUS OH
43214-3903
US

IV. Provider business mailing address

797 THOMAS LN
COLUMBUS OH
43214-3903
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-7337
  • Fax:
Mailing address:
  • Phone: 856-983-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QL0400X
TaxonomyLithotripsy Clinic/Center
License Number0600101241
License Number StateNJ

VIII. Authorized Official

Name: MRS. DEBORAH HAGGETT
Title or Position: ADMINISTRATOR
Credential:
Phone: 856-983-7337