Provider Demographics
NPI:1275733255
Name:ULTIMA CHIROPRACTIC & REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:ULTIMA CHIROPRACTIC & REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SURIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-634-8755
Mailing Address - Street 1:600 WINTERS AVE
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3904
Mailing Address - Country:US
Mailing Address - Phone:201-634-8755
Mailing Address - Fax:201-634-1217
Practice Address - Street 1:600 WINTERS AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3904
Practice Address - Country:US
Practice Address - Phone:201-634-8755
Practice Address - Fax:201-634-1217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00545400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ090845Medicare PIN