Provider Demographics
NPI:1285825802
Name:PARK AVENUE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:PARK AVENUE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:FREDA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-678-6370
Mailing Address - Street 1:85 SOUTH HARRISON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018
Mailing Address - Country:US
Mailing Address - Phone:973-678-6370
Mailing Address - Fax:973-678-6733
Practice Address - Street 1:85 SOUTH HARRISON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018
Practice Address - Country:US
Practice Address - Phone:973-678-6370
Practice Address - Fax:973-678-6733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC3131111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT45115Medicare UPIN
FR450230Medicare PIN