Provider Demographics
NPI:1386063600
Name:ATLANTIC WELLNESS AND SPINE CENTER, LLC
Entity type:Organization
Organization Name:ATLANTIC WELLNESS AND SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:SIOBHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAKENHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-320-2041
Mailing Address - Street 1:1171 FISCHER BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3090
Mailing Address - Country:US
Mailing Address - Phone:732-270-2811
Mailing Address - Fax:732-270-2911
Practice Address - Street 1:1171 FISCHER BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-3090
Practice Address - Country:US
Practice Address - Phone:732-270-2811
Practice Address - Fax:732-270-2911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00666700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty