=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730220328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCEAN COUNTY FAMILY CARE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 12/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 COOKS BRIDGE ROAD SUITE 2-2
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-370-4222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5626 OBERLIN DR SUITE 110
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-625-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF OPERATIONS
-----------------------------------------------------
Name | MR. KENNY HEINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-964-1506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | 25MA08551100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------