Provider Demographics
NPI:1255520888
Name:MONMOUTH FAMILY CHIROPRACTIC, PC
Entity type:Organization
Organization Name:MONMOUTH FAMILY CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OF CORP CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:WALDEMAR
Authorized Official - Last Name:HENDERIKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-530-7711
Mailing Address - Street 1:PO BOX 7425
Mailing Address - Street 2:MONMOUTH FAMILY CHIROPRACTIC
Mailing Address - City:SHREWBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702
Mailing Address - Country:US
Mailing Address - Phone:735-307-7111
Mailing Address - Fax:732-530-9708
Practice Address - Street 1:740 BROAD ST
Practice Address - Street 2:MONMOUTH FAMILY CHIROPRACTIC PC
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702
Practice Address - Country:US
Practice Address - Phone:732-530-7711
Practice Address - Fax:730-530-9708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC3021111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
626052Medicare UPIN