Provider Demographics
NPI:1457549990
Name:COMMUNITY CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:COMMUNITY CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-742-0584
Mailing Address - Street 1:357 GREENWOOD AVE
Mailing Address - Street 2:P.O. BOX 559
Mailing Address - City:GLOUCESTER CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-1604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:357 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:GLOUCESTER CITY
Practice Address - State:NJ
Practice Address - Zip Code:08030-1604
Practice Address - Country:US
Practice Address - Phone:856-742-0584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2144261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3042308Medicaid
NJ1609090216OtherNPI
486475Medicare PIN