Provider Demographics
NPI:1114195500
Name:DEMRECA LLC
Entity Type:Organization
Organization Name:DEMRECA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIERKES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-624-8986
Mailing Address - Street 1:261 51ST ST
Mailing Address - Street 2:
Mailing Address - City:AVALON
Mailing Address - State:NJ
Mailing Address - Zip Code:08202-1310
Mailing Address - Country:US
Mailing Address - Phone:609-624-8986
Mailing Address - Fax:609-624-9098
Practice Address - Street 1:261 51ST ST
Practice Address - Street 2:
Practice Address - City:AVALON
Practice Address - State:NJ
Practice Address - Zip Code:08202-1310
Practice Address - Country:US
Practice Address - Phone:609-624-8986
Practice Address - Fax:609-624-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty