Provider Demographics
NPI:1215327408
Name:NJ CHIROPRACTIC AND PHYSICAL THERAPY WELLNESS CENTER LLC
Entity type:Organization
Organization Name:NJ CHIROPRACTIC AND PHYSICAL THERAPY WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:201-963-0200
Mailing Address - Street 1:3000 JOHN F KENNEDY BLVD STE 316
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-3817
Mailing Address - Country:US
Mailing Address - Phone:201-963-0200
Mailing Address - Fax:201-222-1364
Practice Address - Street 1:3000 JOHN F KENNEDY BLVD STE 316
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-3817
Practice Address - Country:US
Practice Address - Phone:201-963-0200
Practice Address - Fax:201-222-1364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00704200111NR0400X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ38MC00704200OtherLICENSE