Provider Demographics
NPI:1003118456
Name:SOUTH SHORE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:SOUTH SHORE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-390-8772
Mailing Address - Street 1:1217 ROUTE 9
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PALERMO
Mailing Address - State:NJ
Mailing Address - Zip Code:08230
Mailing Address - Country:US
Mailing Address - Phone:609-390-8772
Mailing Address - Fax:609-390-8699
Practice Address - Street 1:1217 ROUTE 9
Practice Address - Street 2:SUITE 101
Practice Address - City:PALERMO
Practice Address - State:NJ
Practice Address - Zip Code:08230
Practice Address - Country:US
Practice Address - Phone:609-390-8772
Practice Address - Fax:609-390-8699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC03565111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ470338Medicare PIN