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General NPI Number Information
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NPI Number | 1699066225
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Entity Type | Organization
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Legal Business Name | SPRING SPA DEPOT CORPORATION
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Dates
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Enumeration Date | 04/30/2011
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Last Update Date | 04/30/2011
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Provider Practice Location Address
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Address Line | 123 CLIFFORD ST
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City | NEWARK
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State | NJ
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Zip | 07105-1950
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Country | US
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Telephone | 973-388-3258
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 32534
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City | NEWARK
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State | NJ
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Zip | 07102-0934
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARIS L SILEGA
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Credential | M.D
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Telephone | 973-388-3258
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 273Y00000X
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Taxonomy Name | Rehabilitation Hospital Unit
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License Number |
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License Number State |
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