Provider Demographics
NPI:1598898017
Name:CEDAR BROOK CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CEDAR BROOK CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DICICCO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-561-1150
Mailing Address - Street 1:P. O. BOX 308
Mailing Address - Street 2:
Mailing Address - City:CEDAR BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08018-0308
Mailing Address - Country:US
Mailing Address - Phone:609-561-1150
Mailing Address - Fax:
Practice Address - Street 1:1 MYERS AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009
Practice Address - Country:US
Practice Address - Phone:609-561-1150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00418400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty