Provider Demographics
NPI:1780970053
Name:DRUCK, CARLY (LAC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:DRUCK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LASALLE AVE
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-1943
Mailing Address - Country:US
Mailing Address - Phone:973-634-7569
Mailing Address - Fax:
Practice Address - Street 1:811 AMBOY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3275
Practice Address - Country:US
Practice Address - Phone:609-369-9241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00072200171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist