=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124422431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKYBRIDGE HEALTHCARE LIMITED LIABILITY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2014
-----------------------------------------------------
Last Update Date | 06/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 RTE 202/206
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-1746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-704-8778
-----------------------------------------------------
Fax | 908-704-8172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 RTE 202/206
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-1746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-704-8778
-----------------------------------------------------
Fax | 908-704-8172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. DEBORAH KUGLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-704-8778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | 25MD002274800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------