Provider Demographics
NPI:1376888941
Name:MLM CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:MLM CHIROPRACTIC, LLC
Other - Org Name:SOUTH JERSEY SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LANZILOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-654-1330
Mailing Address - Street 1:133-B JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055
Mailing Address - Country:US
Mailing Address - Phone:609-654-1330
Mailing Address - Fax:609-714-1612
Practice Address - Street 1:133-B JACKSON RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055
Practice Address - Country:US
Practice Address - Phone:609-654-1330
Practice Address - Fax:609-714-1612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00557400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ037978Medicare PIN