Provider Demographics
NPI:1518172360
Name:SM CHIROPRACTIC&PAIN CLINIC, P.C.
Entity Type:Organization
Organization Name:SM CHIROPRACTIC&PAIN CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-886-7080
Mailing Address - Street 1:810 ABBOTT BLVD
Mailing Address - Street 2:#304
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-4151
Mailing Address - Country:US
Mailing Address - Phone:201-886-7080
Mailing Address - Fax:201-886-8069
Practice Address - Street 1:810 ABBOTT BLVD
Practice Address - Street 2:#304
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-4151
Practice Address - Country:US
Practice Address - Phone:201-886-7080
Practice Address - Fax:201-886-8069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC05716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU84066Medicare UPIN
NJ071005Medicare PIN