Provider Demographics
NPI:1427746528
Name:COLTS NECK ANTI-AGING MED CENTER
Entity type:Organization
Organization Name:COLTS NECK ANTI-AGING MED CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDING- GRANADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-232-6887
Mailing Address - Street 1:178 ROUTE 537
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-1678
Mailing Address - Country:US
Mailing Address - Phone:732-431-8000
Mailing Address - Fax:
Practice Address - Street 1:178 ROUTE 537
Practice Address - Street 2:
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-1678
Practice Address - Country:US
Practice Address - Phone:732-431-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-26
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty