Provider Demographics
NPI:1417473950
Name:PRO HEALTH SPORTS AND WELLNESS CENTER ROCKAWAY LLC
Entity Type:Organization
Organization Name:PRO HEALTH SPORTS AND WELLNESS CENTER ROCKAWAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-627-7888
Mailing Address - Street 1:161 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 ROUTE 46
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-3827
Practice Address - Country:US
Practice Address - Phone:973-627-7888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty