Provider Demographics
NPI:1669920658
Name:NEW AGE INFUSIONS
Entity type:Organization
Organization Name:NEW AGE INFUSIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORNISE
Authorized Official - Middle Name:DENEE
Authorized Official - Last Name:LOGAN-BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-415-5921
Mailing Address - Street 1:2545 TWIN CREEKS DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1860
Mailing Address - Country:US
Mailing Address - Phone:510-415-5921
Mailing Address - Fax:
Practice Address - Street 1:2545 TWIN CREEKS DR
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1860
Practice Address - Country:US
Practice Address - Phone:510-415-5921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WI0600XNursing Service ProvidersRegistered NurseInfection ControlGroup - Single Specialty