Provider Information for 1285235101
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KEITH BROUCA
Sex: Male
NPI: 1285235101
Last Updated: 2025-02-04
Certification Date: 2025-02-04
Certification Date: 2025-02-04
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1285235101 | ||||||||
| Enumeration Date | 2020-11-06 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 217 GLENRIDGE AVE STE 2 MONTCLAIR, NJ 07042-3753 United States Phone: | Fax: | ||||||||
| Primary Practice Address | 217 GLENRIDGE AVE STE 2 MONTCLAIR, NJ 07042-3753 United States Phone: 201-293-0115 | Fax: | ||||||||
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