Provider Demographics
NPI:1639458094
Name:BACK PAIN REHAB CENTER FOR TREATMENT OF BACK PAIN LLC
Entity Type:Organization
Organization Name:BACK PAIN REHAB CENTER FOR TREATMENT OF BACK PAIN LLC
Other - Org Name:BACK PAIN REHAB LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:N
Authorized Official - Last Name:COLLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-750-7246
Mailing Address - Street 1:12 WORTENDYKE RD
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-2046
Mailing Address - Country:US
Mailing Address - Phone:201-750-7246
Mailing Address - Fax:
Practice Address - Street 1:12 WORTENDYKE RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-2046
Practice Address - Country:US
Practice Address - Phone:201-750-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00430900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty