=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326168840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEPARTMENT OF HEALTH AND SENIOR SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 E STATE ST
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08608-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-777-7734
-----------------------------------------------------
Fax | 609-292-0296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 364
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08625-0364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-777-7734
-----------------------------------------------------
Fax | 609-292-0296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HLTH SCIENCE SPECIALIST PART C COOR
-----------------------------------------------------
Name | MS. TERRY L HARRISON
-----------------------------------------------------
Credential | MED
-----------------------------------------------------
Telephone | 609-777-7734
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------