Provider Demographics
NPI:1902858038
Name:WELLNESS ONE OF SOUTH BERGEN
Entity Type:Organization
Organization Name:WELLNESS ONE OF SOUTH BERGEN
Other - Org Name:FOSTER ENTERPRISES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-933-3040
Mailing Address - Street 1:186 PATERSON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07073-1837
Mailing Address - Country:US
Mailing Address - Phone:201-933-3040
Mailing Address - Fax:201-933-8611
Practice Address - Street 1:186 PATERSON AVE
Practice Address - Street 2:
Practice Address - City:EAST RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07073-1837
Practice Address - Country:US
Practice Address - Phone:201-933-3040
Practice Address - Fax:201-933-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ033533Medicare PIN