Provider Demographics
NPI:1538497151
Name:PST WELLNESS CENTER
Entity Type:Organization
Organization Name:PST WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:STEFAN
Authorized Official - Last Name:TATARENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-865-9565
Mailing Address - Street 1:871 ALLWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012
Mailing Address - Country:US
Mailing Address - Phone:973-865-9565
Mailing Address - Fax:973-365-8004
Practice Address - Street 1:871 ALLWOOD ROAD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012
Practice Address - Country:US
Practice Address - Phone:973-865-9565
Practice Address - Fax:973-365-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00677900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty