MEDICARE: DRC360, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1679964795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRC360, LLC

Provider Business Mailing Address
First Line	:	29 SOUTH ST
Second Line	:
City	:	NEW PROVIDENCE
State	:	NJ
Zip	:	07974-2934
Country	:	US
Telephone Number	:	973-452-9078
Fax Number	:

Provider Business Practice Location Address
First Line	:	29 SOUTH ST
Second Line	:
City	:	NEW PROVIDENCE
State	:	NJ
Zip	:	07974-2934
Country	:	US
Telephone Number	:	973-452-9078
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANTHONY RICHARD CAVAZOS
Credential	:
Telephone Number	:	973-452-9078

Provider Enumeration Date	:	02/11/2015
Last Update Date	:	02/11/2015

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