Provider Demographics
NPI:1871043182
Name:SPINE AND SPORTS MEDICINE OF MANCHESTER
Entity Type:Organization
Organization Name:SPINE AND SPORTS MEDICINE OF MANCHESTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-703-5097
Mailing Address - Street 1:60 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:NJ
Mailing Address - Zip Code:08759-2921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 LACEY RD
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:NJ
Practice Address - Zip Code:08759-2921
Practice Address - Country:US
Practice Address - Phone:732-408-4492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09673700332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site