Provider Demographics
NPI:1376649764
Name:FONTANAROSA CHIROPRACTIC INC
Entity Type:Organization
Organization Name:FONTANAROSA CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEREMIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-423-9600
Mailing Address - Street 1:274 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-1962
Mailing Address - Country:US
Mailing Address - Phone:973-423-9600
Mailing Address - Fax:
Practice Address - Street 1:274 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-1962
Practice Address - Country:US
Practice Address - Phone:973-423-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4435111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ799101Medicare ID - Type UnspecifiedMEDICARE