Provider Demographics
NPI:1235327081
Name:GIBBSTOWN CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:GIBBSTOWN CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAISE
Authorized Official - Middle Name:KONRAD
Authorized Official - Last Name:GLODOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-423-3899
Mailing Address - Street 1:360 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GIBBSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08027-1470
Mailing Address - Country:US
Mailing Address - Phone:856-423-3899
Mailing Address - Fax:856-423-5450
Practice Address - Street 1:360 E BROAD ST
Practice Address - Street 2:
Practice Address - City:GIBBSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08027-1470
Practice Address - Country:US
Practice Address - Phone:856-423-3899
Practice Address - Fax:856-423-5450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMCO3280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2096200Medicaid
NJ481114Medicare PIN
NJT91809Medicare UPIN