Provider Demographics
NPI:1649606567
Name:BLEEKER STREET CHIROPRACTIC LLC
Entity type:Organization
Organization Name:BLEEKER STREET CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-230-4222
Mailing Address - Street 1:45 BLEEKER ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1913
Mailing Address - Country:US
Mailing Address - Phone:973-230-4222
Mailing Address - Fax:973-230-2260
Practice Address - Street 1:45 BLEEKER ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1913
Practice Address - Country:US
Practice Address - Phone:973-230-4222
Practice Address - Fax:973-230-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC04563111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU53261Medicare UPIN