Organization Name: | BROAD STREET WELLNESS CENTER |
NPI Number: | 1235371576 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | MARINA BELOZERSKY (OFFICE MANAGER) |
Mailing Address: | 642 Broad St 2nd Fl; Ste 9 Clifton |
State: | NJ US |
Postal Code: | 070131615 |
Phone Number: | 9736149500 |
Fax Number: | |
NPI Enumeration Date: | 04/01/2009 |
NPI Last Update Date: | 06/17/2009 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NJ |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |