Facts
- Status
- A
- Credential
- ATC, LAT
- Type
- Individual
- Enumeration date
- 2016-10-03
- Last updated
- 2016-10-03
Licenses
- License NJ
- 25MT00220000
- License PA
- RT006193
Location
- Practice location
- 6 ELMWOOD DR
- City
- TABERNACLE NJ
- Postal code
- 080889356
- Phone
- 609-784-5154
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.