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General NPI Number Information
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NPI Number | 1104949528
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Entity Type | Organization
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Legal Business Name | SHORE SURGICAL ASSISTANT SERVICE, LLC
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 05/21/2020
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Provider Practice Location Address
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Address Line | 62 TUCKAHOE RD
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City | DOROTHY
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State | NJ
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Zip | 08317-9702
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Country | US
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Telephone | 609-476-4624
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 331
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City | MAYS LANDING
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State | NJ
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Zip | 08330-0331
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Country | US
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Telephone | 973-957-0551
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Fax | 866-396-3054
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Authorized Official
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Title or Position | OWNER
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Name | MR. GARY A BUCK
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Credential | CRNFA
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Telephone | 609-476-4624
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WR0006X
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Taxonomy Name | Registered Nurse First Assistant
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License Number | 26NO09467800
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License Number State | NJ
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