Provider Demographics
NPI:1144092966
Name:TRIADA INTERGRATIVE MEDICINE AND WELLNESS LLC
Entity type:Organization
Organization Name:TRIADA INTERGRATIVE MEDICINE AND WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-824-1480
Mailing Address - Street 1:1300 LIBERTY PL
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5710
Mailing Address - Country:US
Mailing Address - Phone:410-824-1480
Mailing Address - Fax:410-824-1482
Practice Address - Street 1:1300 LIBERTY PL
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5710
Practice Address - Country:US
Practice Address - Phone:856-818-4054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-25
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty