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General NPI Number Information
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NPI Number | 1396335675
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Entity Type | Organization
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Legal Business Name | GLUTALITY PROVIDER GROUP OF NEW JERSEY, PA.
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Dates
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Enumeration Date | 01/21/2021
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Last Update Date | 07/21/2025
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Provider Practice Location Address
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Address Line | 3600 ROUTE 66 STE 150
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City | NEPTUNE
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State | NJ
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Zip | 07753-2645
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Country | US
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Telephone | 561-678-2026
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Fax |
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Provider Business Mailing Address
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Address Line | 401 FAIRWAY DR STE 200
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City | DEERFIELD BEACH
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State | FL
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Zip | 33441-1800
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Country | US
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Telephone | 561-678-2026
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MITCHELL STOTTLAND
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Credential |
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Telephone | 561-678-2026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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