Provider Demographics
NPI:1235302639
Name:SOUTH JERSEY SPINAL CARE CENTER, LLC
Entity Type:Organization
Organization Name:SOUTH JERSEY SPINAL CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DEPOLIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:609-653-0700
Mailing Address - Street 1:1201 NEW RD
Mailing Address - Street 2:SUITE 117-B
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1150
Mailing Address - Country:US
Mailing Address - Phone:609-653-0700
Mailing Address - Fax:609-653-0017
Practice Address - Street 1:1201 NEW RD
Practice Address - Street 2:SUITE 117-B
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1150
Practice Address - Country:US
Practice Address - Phone:609-653-0700
Practice Address - Fax:609-653-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00336300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ156894Medicare PIN