1174691505 NPI number — RED BANK FAMILY CHIROPRACTIC CLINIC PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174691505 NPI number — RED BANK FAMILY CHIROPRACTIC CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED BANK FAMILY CHIROPRACTIC CLINIC PA
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:
1174691505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 RECKLESS PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED BANK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07701-1703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-842-5246
Provider Business Mailing Address Fax Number:
732-842-5246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47 RECKLESS PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED BANK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07701-1703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-842-5246
Provider Business Practice Location Address Fax Number:
732-842-5246
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
MARC
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
732-842-5246

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  38MC00202500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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