Provider Demographics
NPI:1407165111
Name:SPINE SPECIALIST
Entity Type:Organization
Organization Name:SPINE SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-742-0927
Mailing Address - Street 1:PO BOX 7036
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-7036
Mailing Address - Country:US
Mailing Address - Phone:973-742-0927
Mailing Address - Fax:888-373-2114
Practice Address - Street 1:1187 MAIN AVE STE 1D
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2252
Practice Address - Country:US
Practice Address - Phone:973-742-0927
Practice Address - Fax:888-373-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00673900111NN0400X
NYX0116921111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty