Provider Demographics
NPI:1033411715
Name:JOHN LONGO
Entity Type:Organization
Organization Name:JOHN LONGO
Other - Org Name:PARK CHIROPRACTIC CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:LONGO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-661-2303
Mailing Address - Street 1:715 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1021
Mailing Address - Country:US
Mailing Address - Phone:973-661-2303
Mailing Address - Fax:973-661-9141
Practice Address - Street 1:715 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1021
Practice Address - Country:US
Practice Address - Phone:973-661-2303
Practice Address - Fax:973-661-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00205200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1474103Medicaid
NJLO452087Medicare PIN
NJT45241Medicare UPIN