Provider Demographics
NPI:1952472458
Name:SPINE AND SPORTS REHAB. INSTITUTE
Entity Type:Organization
Organization Name:SPINE AND SPORTS REHAB. INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-223-5550
Mailing Address - Street 1:1800 STATE ROUTE 34
Mailing Address - Street 2:BLDGE # 3
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9168
Mailing Address - Country:US
Mailing Address - Phone:732-223-5550
Mailing Address - Fax:732-280-0233
Practice Address - Street 1:1800 STATE ROUTE 34
Practice Address - Street 2:BLDGE # 3
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719-9168
Practice Address - Country:US
Practice Address - Phone:732-223-5550
Practice Address - Fax:732-280-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00311800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT45292Medicare UPIN
NJ077050Medicare ID - Type Unspecified