Provider Demographics
NPI:1265899538
Name:BACK & SPINE CENTER OF PASSAIC, LLC
Entity type:Organization
Organization Name:BACK & SPINE CENTER OF PASSAIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENATO
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAPPELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-473-7200
Mailing Address - Street 1:647 MAIN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4934
Mailing Address - Country:US
Mailing Address - Phone:973-473-7200
Mailing Address - Fax:973-473-7202
Practice Address - Street 1:647 MAIN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4934
Practice Address - Country:US
Practice Address - Phone:973-473-7200
Practice Address - Fax:973-473-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-18
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00550700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty