Provider Demographics
NPI:1336698349
Name:ATLANTIC BACK AND BODY CLINIC LLC
Entity Type:Organization
Organization Name:ATLANTIC BACK AND BODY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MALYNN
Authorized Official - Middle Name:T
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-989-8850
Mailing Address - Street 1:8 QUAKERBRIDGE PLZ STE 1
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-1255
Mailing Address - Country:US
Mailing Address - Phone:310-989-8850
Mailing Address - Fax:
Practice Address - Street 1:8 QUAKERBRIDGE PLZ STE 1
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-1255
Practice Address - Country:US
Practice Address - Phone:310-989-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00738900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ38MC00738900OtherLICENSE NUMBER