Provider Demographics
NPI:1891795514
Name:LICITRA, JOSEPH J (DC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:LICITRA
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 1:300 BROADACRES DR STE 126A
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3153
Mailing Address - Country:US
Mailing Address - Phone:973-470-0632
Mailing Address - Fax:973-893-8259
Practice Address - Street 1:300 BROADACRES DR STE 126
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3153
Practice Address - Country:US
Practice Address - Phone:973-470-0632
Practice Address - Fax:973-893-8259
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00224400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
445444Medicare ID - Type Unspecified