Provider Demographics
NPI:1669946836
Name:ERNST, TIMOTHY GRAYSON (DC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GRAYSON
Last Name:ERNST
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-2165
Mailing Address - Country:US
Mailing Address - Phone:910-330-4677
Mailing Address - Fax:
Practice Address - Street 1:135 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-2165
Practice Address - Country:US
Practice Address - Phone:910-330-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00754900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor