Provider Demographics
NPI:1942789037
Name:PROFESSIONAL SPORT & SPINE LLC
Entity Type:Organization
Organization Name:PROFESSIONAL SPORT & SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-346-2954
Mailing Address - Street 1:101 ROUTE 130 S- PRESIDENTIAL CENTER
Mailing Address - Street 2:WASHINGTON BLDG SUITE 10
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 ROUTE 130 S- PRESIDENTIAL CENTER
Practice Address - Street 2:WASHINGTON BLDG SUITE 10
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077
Practice Address - Country:US
Practice Address - Phone:609-346-2954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00738000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty