Provider Demographics
NPI:1780005801
Name:BACK PAIN HOME SUPPLIES
Entity Type:Organization
Organization Name:BACK PAIN HOME SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-691-0482
Mailing Address - Street 1:1133 E CHESTNUT AVE
Mailing Address - Street 2:BLDG 2
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-5001
Mailing Address - Country:US
Mailing Address - Phone:856-691-0482
Mailing Address - Fax:856-690-8822
Practice Address - Street 1:1133 E CHESTNUT AVE
Practice Address - Street 2:BLDG 2
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5001
Practice Address - Country:US
Practice Address - Phone:856-691-0482
Practice Address - Fax:856-690-8822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0400601424332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7032160001Medicare NSC