Provider Demographics
NPI:1083773923
Name:PENCZAK FAMILY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:PENCZAK FAMILY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-974-7022
Mailing Address - Street 1:2041 ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719
Mailing Address - Country:US
Mailing Address - Phone:732-974-7022
Mailing Address - Fax:732-974-7023
Practice Address - Street 1:2041 ROUTE 35
Practice Address - Street 2:
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719
Practice Address - Country:US
Practice Address - Phone:732-974-7022
Practice Address - Fax:732-974-7023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00554100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2273901000OtherAMERIHEALTH PPO PIN
NJV01647Medicare UPIN
NJ084043Medicare PIN