Provider Demographics
NPI:1306594163
Name:ETERNALLY ACP PC
Entity type:Organization
Organization Name:ETERNALLY ACP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYANK
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-764-4704
Mailing Address - Street 1:104 FORREST AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-2215
Mailing Address - Country:US
Mailing Address - Phone:267-764-4704
Mailing Address - Fax:
Practice Address - Street 1:693 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-5043
Practice Address - Country:US
Practice Address - Phone:267-764-4704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty