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General NPI Number Information
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NPI Number | 1932316403
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Entity Type | Organization
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Legal Business Name | AGAPE PEDIATRIC CENTER
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Dates
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Enumeration Date | 05/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 185 CENTRAL AVE SUITE 401
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City | EAST ORANGE
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State | NJ
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Zip | 07018-3332
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Country | US
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Telephone | 973-673-6311
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Fax | 973-673-6511
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Provider Business Mailing Address
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Address Line | 185 CENTRAL AVE SUITE 401
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City | EAST ORANGE
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State | NJ
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Zip | 07018-3332
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Country | US
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Telephone | 973-673-6311
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Fax | 973-673-6511
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Authorized Official
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Title or Position | DIRECT OWNER
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Name | DR. ADRIAN BRUCE WALCOTT
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Credential | M.D.
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Telephone | 973-673-6311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MA59554
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License Number State | NJ
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