Provider Demographics
NPI:1235576109
Name:CENTER FOR DYNAMIC AGING, LLC
Entity Type:Organization
Organization Name:CENTER FOR DYNAMIC AGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:F
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:201-363-8871
Mailing Address - Street 1:1530 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5471
Mailing Address - Country:US
Mailing Address - Phone:201-363-8871
Mailing Address - Fax:201-363-8873
Practice Address - Street 1:1530 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5471
Practice Address - Country:US
Practice Address - Phone:201-363-8871
Practice Address - Fax:201-363-8873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA063457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty