Provider Demographics
NPI:1366433534
Name:SRC PENDING CONSULT MANAGEMENT
Entity type:Organization
Organization Name:SRC PENDING CONSULT MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTALA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:609-562-6312
Mailing Address - Street 1:1312 PARIS CT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3724
Mailing Address - Country:US
Mailing Address - Phone:732-267-7737
Mailing Address - Fax:
Practice Address - Street 1:5250 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:FORT DIX
Practice Address - State:NJ
Practice Address - Zip Code:08640-5058
Practice Address - Country:US
Practice Address - Phone:609-562-6312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR09534400261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center