Provider Demographics
NPI:1699816538
Name:WRAITH, BRIAN M (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:WRAITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 BERGEN BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRVIEW
Mailing Address - State:NJ
Mailing Address - Zip Code:07022-1334
Mailing Address - Country:US
Mailing Address - Phone:201-945-2032
Mailing Address - Fax:201-945-8873
Practice Address - Street 1:323 BERGEN BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:FAIRVIEW
Practice Address - State:NJ
Practice Address - Zip Code:07022-1334
Practice Address - Country:US
Practice Address - Phone:201-945-2032
Practice Address - Fax:201-945-8873
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00622800111N00000X
NYX009946111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ095364Medicare UPIN
NYU89781Medicare UPIN