Provider Demographics
NPI: | 1154859122 |
---|---|
Name: | PRIME TOTAL PAIN CLINIC PC |
Entity Type: | Organization |
Organization Name: | PRIME TOTAL PAIN CLINIC PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | SEUNG |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LEE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 201-290-5415 |
Mailing Address - Street 1: | 118 BROAD AVE. |
Mailing Address - Street 2: | SUITE 10 |
Mailing Address - City: | PALISADES PARK |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 07650 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 201-313-1122 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 118 BROAD AVE STE 10 |
Practice Address - Street 2: | |
Practice Address - City: | PALISADES PARK |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 07650-2717 |
Practice Address - Country: | US |
Practice Address - Phone: | 201-313-1122 |
Practice Address - Fax: | 201-941-1157 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-06-02 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | 38MC00671900 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty |