Provider Demographics
NPI:1699227686
Name:NEW JERSEY PAIN CENTER PC
Entity Type:Organization
Organization Name:NEW JERSEY PAIN CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INSUN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-575-2783
Mailing Address - Street 1:100 WINSTON DR APT 6BN
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-3264
Mailing Address - Country:US
Mailing Address - Phone:201-575-2783
Mailing Address - Fax:
Practice Address - Street 1:845 BROAD AVE
Practice Address - Street 2:102
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-1002
Practice Address - Country:US
Practice Address - Phone:201-575-2783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-26
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC0052330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty