Provider Demographics
NPI:1265463830
Name:NORTHEASTERN SPINAL HEALTH AND REHABILITATION LLC
Entity Type:Organization
Organization Name:NORTHEASTERN SPINAL HEALTH AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROMAN
Authorized Official - Last Name:CZUPAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-812-0202
Mailing Address - Street 1:1037 ROUTE 46 STE 203
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-2459
Mailing Address - Country:US
Mailing Address - Phone:973-812-0202
Mailing Address - Fax:973-812-0505
Practice Address - Street 1:1037 ROUTE 46 STE 203
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2459
Practice Address - Country:US
Practice Address - Phone:973-812-0202
Practice Address - Fax:973-812-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00628700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60192385OtherNJ HEALTH PROVIDER