Provider Demographics
NPI:1659658987
Name:SPORTSMED CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:SPORTSMED CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-803-7695
Mailing Address - Street 1:784 FRANKLIN AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-1306
Mailing Address - Country:US
Mailing Address - Phone:201-819-0090
Mailing Address - Fax:201-797-1055
Practice Address - Street 1:784 FRANKLIN AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:FRANKLIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07417-1306
Practice Address - Country:US
Practice Address - Phone:201-819-0090
Practice Address - Fax:201-797-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00313700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty