Provider Demographics
NPI:1487056768
Name:GARDEN STATE RADIOLOGY NETWORK, LLC
Entity type:Organization
Organization Name:GARDEN STATE RADIOLOGY NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:SKULTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-428-9644
Mailing Address - Street 1:1510 COTNER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:310-966-8553
Practice Address - Street 1:157 FRIES MILL RD
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2017
Practice Address - Country:US
Practice Address - Phone:856-677-1010
Practice Address - Fax:856-677-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ23723261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology