Provider Demographics
NPI:1396921268
Name:EAST BLACKWELL CHIROPRACTIC, INC
Entity type:Organization
Organization Name:EAST BLACKWELL CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-361-3500
Mailing Address - Street 1:2 E BLACKWELL ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07801-4645
Mailing Address - Country:US
Mailing Address - Phone:973-361-3500
Mailing Address - Fax:973-361-1360
Practice Address - Street 1:2 E BLACKWELL STREET
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801
Practice Address - Country:US
Practice Address - Phone:973-361-3500
Practice Address - Fax:973-361-1360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC04592111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ619013PM7Medicare PIN
NJU54489Medicare UPIN