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General NPI Number Information
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NPI Number | 1053603431
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Entity Type | Organization
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Legal Business Name | BRIANJRDUSTINANDREW
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Dates
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Enumeration Date | 05/04/2011
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Last Update Date | 05/04/2011
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Provider Practice Location Address
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Address Line | 413 SALEM HANCOCKS BRIDGE RD
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City | SALEM
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State | NJ
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Zip | 08079-9418
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Country | US
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Telephone | 856-935-0427
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Fax | 856-935-0427
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Provider Business Mailing Address
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Address Line | 413 SALEM HANCOCKS BRIDGE RD
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City | SALEM
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State | NJ
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Zip | 08079-9418
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Country | US
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Telephone | 856-935-0427
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Fax | 856-935-0427
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | MRS. DAWN MICHELE HARRIS
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Credential | CNA/CHHA/EMT
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Telephone | 856-935-0427
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 26NH07335300
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | NANJ0608042655
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License Number State | NJ
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