1285079590 NPI number — PARK PLACE CHIROPRACTIC AND REHABILITATION

Table of content: (NPI 1285079590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285079590 NPI number — PARK PLACE CHIROPRACTIC AND REHABILITATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK PLACE CHIROPRACTIC AND REHABILITATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285079590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 ACADEMY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07102-2923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-824-2225
Provider Business Mailing Address Fax Number:
973-824-5454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 ACADEMY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07102-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-824-2225
Provider Business Practice Location Address Fax Number:
973-824-5454
Provider Enumeration Date:
05/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BOZIAN
Authorized Official First Name:
GARY
Authorized Official Middle Name:
STEPAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
973-824-2225

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  MC03260 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X , with the licence number: 38MCOO326000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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