Provider Demographics
NPI:1124033212
Name:PAVONIA SPINE & REHABILITATION,PC
Entity Type:Organization
Organization Name:PAVONIA SPINE & REHABILITATION,PC
Other - Org Name:BARTECK WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARTECK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-710-5420
Mailing Address - Street 1:36-42 NEWARK ST
Mailing Address - Street 2:SUIRE 301
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-5654
Mailing Address - Country:US
Mailing Address - Phone:201-710-5420
Mailing Address - Fax:201-710-5419
Practice Address - Street 1:36-42 NEWARK ST
Practice Address - Street 2:SUITE 301
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-5654
Practice Address - Country:US
Practice Address - Phone:201-710-5420
Practice Address - Fax:201-710-5419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC04987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX ID#
NJ092209Medicare ID - Type UnspecifiedGROUP PROVIDER #
NJ=========OtherTAX ID#