Provider Demographics
NPI:1487936951
Name:MOUNTAIN CHIROPRACTIC CENTER LLC
Entity type:Organization
Organization Name:MOUNTAIN CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:KEVANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:908-561-2323
Mailing Address - Street 1:31 C MOUNTAIN BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5617
Mailing Address - Country:US
Mailing Address - Phone:908-561-2323
Mailing Address - Fax:908-561-3434
Practice Address - Street 1:31 C MOUNTAIN BOULEVARD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5617
Practice Address - Country:US
Practice Address - Phone:908-561-2323
Practice Address - Fax:908-561-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00441700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU48436Medicare UPIN
NJ754383Medicare PIN