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General NPI Number Information
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NPI Number | 1316235880
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Entity Type | Organization
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Legal Business Name | PERSONALIZED PRIMARY CARE CENTER, LLC
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Dates
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Enumeration Date | 07/18/2011
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Last Update Date | 07/18/2011
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Provider Practice Location Address
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Address Line | 2301 E EVESHAM RD SUITE 407
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City | VOORHEES
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State | NJ
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Zip | 08043-4501
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Country | US
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Telephone | 856-685-7285
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Fax | 856-685-7675
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Provider Business Mailing Address
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Address Line | 2301 E EVESHAM RD SUITE 407
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City | VOORHEES
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State | NJ
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Zip | 08043-4501
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Country | US
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Telephone | 856-685-7285
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Fax | 856-685-7675
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Authorized Official
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Title or Position | PHYSICIAN
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Name | RALPH F. COSTA
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Credential | MD
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Telephone | 856-685-7285
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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