Provider Demographics
NPI:1336296375
Name:SELIMO, SAMUEL P (DC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:P
Last Name:SELIMO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-2153
Mailing Address - Country:US
Mailing Address - Phone:973-299-2430
Mailing Address - Fax:973-299-2433
Practice Address - Street 1:125 MADISON ST
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-2153
Practice Address - Country:US
Practice Address - Phone:973-299-2430
Practice Address - Fax:973-299-2433
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC02363111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3151240Medicaid
NJ451831Medicare ID - Type Unspecified