Provider Demographics
NPI:1457301061
Name:BLANK, PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:BLANK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N WOOD AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-4160
Mailing Address - Country:US
Mailing Address - Phone:908-925-1371
Mailing Address - Fax:908-925-0332
Practice Address - Street 1:500 N WOOD AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4160
Practice Address - Country:US
Practice Address - Phone:908-925-1371
Practice Address - Fax:908-925-0332
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1734111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26-4777647OtherEIN
NJ26-4777647OtherEIN