Provider Demographics
NPI:1215073515
Name:OLD TAPPAN CHIROPRACTIC, PA
Entity type:Organization
Organization Name:OLD TAPPAN CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LAROCCA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-497-6612
Mailing Address - Street 1:1 DEWOLF RD STE 208
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7084
Mailing Address - Country:US
Mailing Address - Phone:201-497-6612
Mailing Address - Fax:201-497-6614
Practice Address - Street 1:1 DEWOLF RD STE 208
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675
Practice Address - Country:US
Practice Address - Phone:201-497-6612
Practice Address - Fax:201-497-6614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00582100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ084539Medicare UPIN