Provider Demographics
NPI:1790735959
Name:FAIR LAWN SPINE & PT CARE LLC
Entity Type:Organization
Organization Name:FAIR LAWN SPINE & PT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:THIMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-794-6868
Mailing Address - Street 1:19-21 FAIR LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-794-6868
Mailing Address - Fax:201-794-6003
Practice Address - Street 1:19-21 FAIR LAWN AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-794-6868
Practice Address - Fax:201-794-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ086617Medicare ID - Type Unspecified