Provider Demographics
NPI:1588798409
Name:NORTHEAST SPINE & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:NORTHEAST SPINE & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PARIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-827-0800
Mailing Address - Street 1:1043 RARITAN RD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1316
Mailing Address - Country:US
Mailing Address - Phone:732-827-0800
Mailing Address - Fax:732-827-0826
Practice Address - Street 1:1043 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1316
Practice Address - Country:US
Practice Address - Phone:732-827-0800
Practice Address - Fax:732-827-0826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6205570001Medicare NSC