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General NPI Number Information
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NPI Number | 1134545429
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Entity Type | Organization
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Legal Business Name | CANDLEWOOD PEDIATRICS
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Dates
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Enumeration Date | 03/11/2014
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Last Update Date | 04/04/2014
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Provider Practice Location Address
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Address Line | 1540 HWY. 138 SUITE 105
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City | WALL
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State | NJ
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Zip | 07719
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Country | US
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Telephone | 732-280-3100
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Fax | 732-280-3103
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Provider Business Mailing Address
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Address Line | 1540 HWY. 138 SUITE 105
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City | WALL
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State | NJ
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Zip | 07719
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Country | US
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Telephone | 732-280-3100
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Fax | 732-280-3103
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Authorized Official
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Title or Position | PROPRIETOR/MEDICAL DOCTOR
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Name | TATYANA SHKOLNAYA
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Credential | M.D.
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Telephone | 732-280-3100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 25MA06638500
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License Number State | NJ
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