=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053906263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPIRAS HEALTH OF NEW JERSEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2021
-----------------------------------------------------
Last Update Date | 03/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5214 MARYLAND WAY STE 210
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-5071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-403-0631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5214 MARYLAND WAY STE 210
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-5071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-403-0631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BROOK BISHOP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-403-0631
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------