Provider Demographics
NPI:1700163318
Name:THE SPINE INSTITUTE & SPORT MEDICINE OF NEW JERSEY INCORPORATE
Entity Type:Organization
Organization Name:THE SPINE INSTITUTE & SPORT MEDICINE OF NEW JERSEY INCORPORATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-641-3620
Mailing Address - Street 1:418 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3829
Mailing Address - Country:US
Mailing Address - Phone:732-641-3620
Mailing Address - Fax:732-826-3613
Practice Address - Street 1:418 SMITH ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3829
Practice Address - Country:US
Practice Address - Phone:732-641-3620
Practice Address - Fax:732-826-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty