Provider Demographics
NPI:1225370356
Name:OLD HOOK MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:OLD HOOK MEDICAL ASSOCIATES, LLC
Other - Org Name:OLD HOOK MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-964-1506
Mailing Address - Street 1:5626 OBERLIN DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:452 OLD HOOK RD
Practice Address - Street 2:FLOOR 2
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1381
Practice Address - Country:US
Practice Address - Phone:201-666-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX,INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-27
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04377200332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site