Basic Information
| Provider Information | |||||||||
| NPI: | 1750394474 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVOCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVOCARE WEST DEPTFORD PEDIATRICS | ||||||||
| 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: | 8567823300 | ||||||||
| FaxNumber: | 8565048029 | ||||||||
| Practice Location | |||||||||
| Address1: | 646 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | WEST DEPTFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080963145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568792887 | ||||||||
| FaxNumber: | 8568792855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | CANDIA | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8568727053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVOCARE, LLC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/19/2021 | ||||||||
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 | 31D0901275 | 01 | CLIA | OTHER | 31D0953106 | 01 | CLIA | OTHER | 8245908 | 05 | NJ | MEDICAID |