Provider Demographics
NPI:1972662872
Name:DEPOT PARK CHIROPRACTIC CENTER P A
Entity Type:Organization
Organization Name:DEPOT PARK CHIROPRACTIC CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:KOSIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:908-753-5454
Mailing Address - Street 1:311 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-4229
Mailing Address - Country:US
Mailing Address - Phone:908-753-5454
Mailing Address - Fax:908-753-6370
Practice Address - Street 1:311 PARK AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-4229
Practice Address - Country:US
Practice Address - Phone:908-753-5454
Practice Address - Fax:908-753-6370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC03912111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty