Provider Demographics
NPI:1689736811
Name:PURE LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:PURE LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSANIA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:973-768-3651
Mailing Address - Street 1:81 GLENROY RD EAST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004
Mailing Address - Country:US
Mailing Address - Phone:973-768-3651
Mailing Address - Fax:
Practice Address - Street 1:16 WATSESSING AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-768-3651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00648300305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ$$$$$$$$$OtherSOCIAL SECURITY NUMBER