Provider Demographics
NPI:1740462571
Name:WEST PARK CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:WEST PARK CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:7325-171-0990
Mailing Address - Street 1:780 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-1028
Mailing Address - Country:US
Mailing Address - Phone:732-517-1090
Mailing Address - Fax:732-517-1096
Practice Address - Street 1:780 W PARK AVE
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-1028
Practice Address - Country:US
Practice Address - Phone:732-517-1090
Practice Address - Fax:732-517-1096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC005167000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ046288Medicare PIN