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General NPI Number Information
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NPI Number | 1376219402
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Entity Type | Organization
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Legal Business Name | PSYCHE REVIVE LLC
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Dates
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Enumeration Date | 08/18/2021
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Last Update Date | 08/18/2021
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Provider Practice Location Address
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Address Line | 4 SWIMMING RIVER RD STE 101
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City | LINCROFT
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State | NJ
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Zip | 07738-1727
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Country | US
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Telephone | 646-708-3846
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Fax |
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Provider Business Mailing Address
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Address Line | 30 LA JOLLA CT
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City | HOLMDEL
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State | NJ
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Zip | 07733-2520
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Country | US
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Telephone | 347-721-5590
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Fax |
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Authorized Official
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Title or Position | FOUNDING PHYSICIAN
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Name | DR. STEPHEN JAEGER
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Credential | MD
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Telephone | 347-721-5590
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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