Provider Demographics
NPI:1972018778
Name:PRO HEALTH SPORTS AND WELLNESS CENTER CHESTER LLC
Entity Type:Organization
Organization Name:PRO HEALTH SPORTS AND WELLNESS CENTER CHESTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-627-7888
Mailing Address - Street 1:161 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2647
Mailing Address - Country:US
Mailing Address - Phone:973-627-7888
Mailing Address - Fax:973-627-7040
Practice Address - Street 1:169 ROUTE 206
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930
Practice Address - Country:US
Practice Address - Phone:973-627-7888
Practice Address - Fax:973-627-7040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty