Provider Demographics
NPI:1043500382
Name:PROACTIVE CHIROPRACTIC REHABILITATION CENTER
Entity Type:Organization
Organization Name:PROACTIVE CHIROPRACTIC REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ANNUNZIATA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-829-8100
Mailing Address - Street 1:2010 NEW ALBANY RD
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-3535
Mailing Address - Country:US
Mailing Address - Phone:856-829-8100
Mailing Address - Fax:856-829-9040
Practice Address - Street 1:2010 NEW ALBANY RD
Practice Address - Street 2:
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-3535
Practice Address - Country:US
Practice Address - Phone:856-829-8100
Practice Address - Fax:856-829-9040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00656000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty