Provider Demographics
NPI:1922664259
Name:MEDICOR LIFESTYLE MEDICINE, P.A
Entity Type:Organization
Organization Name:MEDICOR LIFESTYLE MEDICINE, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIKTORIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-243-5004
Mailing Address - Street 1:225 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-3060
Mailing Address - Country:US
Mailing Address - Phone:908-243-5004
Mailing Address - Fax:908-904-1403
Practice Address - Street 1:331 US HIGHWAY 206
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-4781
Practice Address - Country:US
Practice Address - Phone:908-243-5004
Practice Address - Fax:908-904-1403
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICOR LIFESTYLE MEDICINE, P.A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty