=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063644607
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SILVER CONTINENCE CARE - NJ, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2009
-----------------------------------------------------
Last Update Date | 03/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10000 LINCOLN DR E SUITE 201
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-988-5508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10000 LINCOLN DR E SUITE 201
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-988-5508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | FRAZER BUNTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-300-6892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------