Provider Demographics
NPI: | 1275801672 |
---|---|
Name: | SUBURBAN ENDOSCOPY CENTER, LLC |
Entity Type: | Organization |
Organization Name: | SUBURBAN ENDOSCOPY CENTER, LLC |
Other - Org Name: | UAP VERONA ENDO |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OFFICER/AUTHORIZED OFFICIAL |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JENETHA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MORAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 972-763-3893 |
Mailing Address - Street 1: | 799 BLOOMFIELD AVE |
Mailing Address - Street 2: | SUITE 101 |
Mailing Address - City: | VERONA |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 07044-1367 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 973-571-1600 |
Mailing Address - Fax: | 973-571-1882 |
Practice Address - Street 1: | 799 BLOOMFIELD AVE |
Practice Address - Street 2: | SUITE 101 |
Practice Address - City: | VERONA |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 07044-1367 |
Practice Address - Country: | US |
Practice Address - Phone: | 973-571-1600 |
Practice Address - Fax: | 973-571-1882 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-12-13 |
Last Update Date: | 2011-12-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Single Specialty |