Provider Demographics
NPI:1134440589
Name:BROADWAY SPINE CARE
Entity type:Organization
Organization Name:BROADWAY SPINE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KAVALIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-766-2648
Mailing Address - Street 1:7711 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5728
Mailing Address - Country:US
Mailing Address - Phone:201-766-2648
Mailing Address - Fax:201-766-2650
Practice Address - Street 1:7711 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5728
Practice Address - Country:US
Practice Address - Phone:201-766-2648
Practice Address - Fax:201-766-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00353600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty