=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295256394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVOCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2017
-----------------------------------------------------
Last Update Date | 11/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 S ROUTE 73 STE B
-----------------------------------------------------
City | HAMMONTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08037-9432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-567-2101
-----------------------------------------------------
Fax | 609-704-9351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 ROUTE 73 N STE 320
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-872-7055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VICE PRESIDENT AND COO
-----------------------------------------------------
Name | CHARLES MCQUEARY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-872-7055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------