Provider Demographics
NPI:1063880011
Name:MINIMALLY INVASIVE AND REGENERATIVE SPINE INSTITUTE
Entity type:Organization
Organization Name:MINIMALLY INVASIVE AND REGENERATIVE SPINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:TOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:PRVULOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-903-4943
Mailing Address - Street 1:1054 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3638
Mailing Address - Country:US
Mailing Address - Phone:973-779-4100
Mailing Address - Fax:
Practice Address - Street 1:1054 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3638
Practice Address - Country:US
Practice Address - Phone:973-779-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06129800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty