Provider Demographics
NPI:1346281037
Name:PETRACCO CHIROPRACTIC CENTER P A
Entity Type:Organization
Organization Name:PETRACCO CHIROPRACTIC CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRACCO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-533-0055
Mailing Address - Street 1:218 NEWARK AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-2736
Mailing Address - Country:US
Mailing Address - Phone:201-533-0055
Mailing Address - Fax:201-533-0066
Practice Address - Street 1:218 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-2736
Practice Address - Country:US
Practice Address - Phone:201-533-0055
Practice Address - Fax:201-533-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00495100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty