Provider Demographics
NPI:1053603431
Name:BRIANJRDUSTINANDREW
Entity type:Organization
Organization Name:BRIANJRDUSTINANDREW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:CNA/CHHA/EMT
Authorized Official - Phone:856-935-0427
Mailing Address - Street 1:413 SALEM HANCOCKS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NJ
Mailing Address - Zip Code:08079-9418
Mailing Address - Country:US
Mailing Address - Phone:856-935-0427
Mailing Address - Fax:856-935-0427
Practice Address - Street 1:413 SALEM HANCOCKS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079-9418
Practice Address - Country:US
Practice Address - Phone:856-935-0427
Practice Address - Fax:856-935-0427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NH07335300261QH0100X
NJNANJ0608042655261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service