Basic Information
| Provider Information | |||||||||
| NPI: | 1194833830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVOCARE, LLC | ||||||||
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| OtherOrganizationName: | ADVOCARE HADDONFIELD PEDIATRIC ASSOCIATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 ROUTE 73 N STE 320 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080533426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568727055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 220 N HADDON AVE | ||||||||
| Address2: | |||||||||
| City: | HADDONFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080332323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564296719 | ||||||||
| FaxNumber: | 8564296868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | CANDIA | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8568727053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVOCARE , LLC | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 31D0117766 | 01 | CLIA | OTHER |