Provider Demographics
NPI:1366565087
Name:ALLERGY & ASTHMA CENTER OF LACEY, LLC
Entity type:Organization
Organization Name:ALLERGY & ASTHMA CENTER OF LACEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:A
Authorized Official - Last Name:TUMALIUAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-693-6464
Mailing Address - Street 1:606 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-2205
Mailing Address - Country:US
Mailing Address - Phone:609-693-6464
Mailing Address - Fax:609-693-6334
Practice Address - Street 1:606 LACEY RD
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-2205
Practice Address - Country:US
Practice Address - Phone:609-693-6464
Practice Address - Fax:609-693-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65918207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ123658Medicare PIN