Provider Demographics
NPI:1912462029
Name:POMEGRANATE WELLNESS HEALTH AESTHETICS
Entity Type:Organization
Organization Name:POMEGRANATE WELLNESS HEALTH AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PANSY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS-LANE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:973-731-6253
Mailing Address - Street 1:203 GIRARD RD N
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2117
Mailing Address - Country:US
Mailing Address - Phone:973-731-6253
Mailing Address - Fax:
Practice Address - Street 1:203 GIRARD RD N
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-2117
Practice Address - Country:US
Practice Address - Phone:973-731-6253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty