Provider Demographics
NPI:1841235330
Name:RUSSELL BROKSTEIN
Entity Type:Organization
Organization Name:RUSSELL BROKSTEIN
Other - Org Name:HOMETOWN FAMILY WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROKSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-780-0044
Mailing Address - Street 1:9 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-1805
Mailing Address - Country:US
Mailing Address - Phone:732-780-0044
Mailing Address - Fax:732-780-3671
Practice Address - Street 1:9 BROADWAY
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-1805
Practice Address - Country:US
Practice Address - Phone:732-780-0044
Practice Address - Fax:732-780-3671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00573400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherBC/BS
NJ084620Medicare PIN
NJV01952Medicare UPIN