=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811319189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONMOUTH COUNTY PAIN MANAGEMENT & WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2014
-----------------------------------------------------
Last Update Date | 08/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1131 BROAD ST STE 104
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-692-9833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1131 BROAD ST STE 104
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-692-9833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | NICOLE KEEGAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 908-692-9833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 25MA08847600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------