Provider Demographics
NPI:1669882486
Name:RENAISSANCE CHIROPRACTIC AND REHABILITATION CENTER, LLC
Entity type:Organization
Organization Name:RENAISSANCE CHIROPRACTIC AND REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:MANAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MENA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-626-4008
Mailing Address - Street 1:26 HOLLY DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8843
Mailing Address - Country:US
Mailing Address - Phone:609-626-4008
Mailing Address - Fax:732-737-9030
Practice Address - Street 1:413 LAKEHURST RD
Practice Address - Street 2:BLDG 2
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-7382
Practice Address - Country:US
Practice Address - Phone:609-626-4008
Practice Address - Fax:732-737-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-01
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00711800111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty