Provider Demographics
NPI:1003042565
Name:CHIROPRACTIC REHABILIATION CENTER OF VERONA, P.C.
Entity Type:Organization
Organization Name:CHIROPRACTIC REHABILIATION CENTER OF VERONA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:FANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-444-3081
Mailing Address - Street 1:155 POMPTON AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-2942
Mailing Address - Country:US
Mailing Address - Phone:973-444-3081
Mailing Address - Fax:
Practice Address - Street 1:155 POMPTON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-2942
Practice Address - Country:US
Practice Address - Phone:973-444-3081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00430500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty