Provider Demographics
NPI:1336338581
Name:TOTAL BODY REHABILITATION LLC
Entity type:Organization
Organization Name:TOTAL BODY REHABILITATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:201-891-1155
Mailing Address - Street 1:260 GODWIN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-2099
Mailing Address - Country:US
Mailing Address - Phone:201-891-1155
Mailing Address - Fax:201-891-5522
Practice Address - Street 1:260 GODWIN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-2099
Practice Address - Country:US
Practice Address - Phone:201-891-1155
Practice Address - Fax:201-891-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6581280001Medicare NSC