Provider Demographics
NPI:1366002651
Name:PRINCETON BRAIN SPINE AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:PRINCETON BRAIN SPINE AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-585-6100
Mailing Address - Street 1:558 LAWRENCE SQUARE BLVD S
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2674
Mailing Address - Country:US
Mailing Address - Phone:609-585-6100
Mailing Address - Fax:
Practice Address - Street 1:558 LAWRENCE SQUARE BLVD S
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2674
Practice Address - Country:US
Practice Address - Phone:609-921-9001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-18
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty