Provider Demographics
NPI:1629271135
Name:186 FAIRFIELD ROAD LLC
Entity Type:Organization
Organization Name:186 FAIRFIELD ROAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:LEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-227-3388
Mailing Address - Street 1:39 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-1438
Mailing Address - Country:US
Mailing Address - Phone:973-227-3388
Mailing Address - Fax:973-227-0887
Practice Address - Street 1:186 FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2423
Practice Address - Country:US
Practice Address - Phone:973-227-3388
Practice Address - Fax:973-227-0887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJY39407Medicare UPIN
NJ093416Medicare ID - Type Unspecified