Provider Demographics
NPI:1164032140
Name:MONTCLAIR SPINE & SPORTS REHAB, LLC
Entity Type:Organization
Organization Name:MONTCLAIR SPINE & SPORTS REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA TORRE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:973-942-0220
Mailing Address - Street 1:54 LEWIS PL
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-2648
Mailing Address - Country:US
Mailing Address - Phone:973-885-8877
Mailing Address - Fax:973-942-0220
Practice Address - Street 1:292 BLOOMFIELD AVE FL 2
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3624
Practice Address - Country:US
Practice Address - Phone:973-942-0220
Practice Address - Fax:973-942-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty