Provider Demographics
NPI:1972783934
Name:PENNSAUKEN SPINE AND REHAB
Entity Type:Organization
Organization Name:PENNSAUKEN SPINE AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIANI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-488-0222
Mailing Address - Street 1:4307 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08110-3023
Mailing Address - Country:US
Mailing Address - Phone:856-488-0222
Mailing Address - Fax:856-488-0233
Practice Address - Street 1:4307 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08110-3023
Practice Address - Country:US
Practice Address - Phone:856-488-0222
Practice Address - Fax:856-488-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00387000111NR0400X
NJ38MC00349500111NR0400X
NJ38MC00319800111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty