Provider Demographics
NPI:1083972442
Name:SPRING SPA DEPOT CORPORATION
Entity Type:Organization
Organization Name:SPRING SPA DEPOT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:SILEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:862-241-1800
Mailing Address - Street 1:PO BOX 32534
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-0934
Mailing Address - Country:US
Mailing Address - Phone:888-412-0570
Mailing Address - Fax:862-241-1800
Practice Address - Street 1:6 GOBLE ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114-2702
Practice Address - Country:US
Practice Address - Phone:888-412-0570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ305R00000X, 320700000X, 332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
964725290OtherDB