Provider Demographics
NPI:1598364127
Name:EDISON CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:EDISON CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUCKSOON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-310-5193
Mailing Address - Street 1:1581 ROUTE 27 UNIT 4
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-3477
Mailing Address - Country:US
Mailing Address - Phone:732-327-0225
Mailing Address - Fax:
Practice Address - Street 1:1581 ROUTE 27 UNIT 4
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-3477
Practice Address - Country:US
Practice Address - Phone:732-327-0225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty