Provider Demographics
NPI:1124325428
Name:THEODORE B. SICILIANO,DC LLC
Entity type:Organization
Organization Name:THEODORE B. SICILIANO,DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:B
Authorized Official - Last Name:SICILIANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-597-9333
Mailing Address - Street 1:720 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST CREEK
Mailing Address - State:NJ
Mailing Address - Zip Code:08092-3121
Mailing Address - Country:US
Mailing Address - Phone:609-597-9333
Mailing Address - Fax:
Practice Address - Street 1:720 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST CREEK
Practice Address - State:NJ
Practice Address - Zip Code:08092-3121
Practice Address - Country:US
Practice Address - Phone:609-597-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00170300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT82455Medicare UPIN