Provider Demographics
NPI:1912055500
Name:SICILIANO, THEODORE B (DC)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:B
Last Name:SICILIANO
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 1:720 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST CREEK
Mailing Address - State:NJ
Mailing Address - Zip Code:08092-3121
Mailing Address - Country:US
Mailing Address - Phone:609-597-9333
Mailing Address - Fax:609-597-4481
Practice Address - Street 1:720 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST CREEK
Practice Address - State:NJ
Practice Address - Zip Code:08092-3121
Practice Address - Country:US
Practice Address - Phone:609-597-9333
Practice Address - Fax:609-597-4481
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00170300111N00000X
NYX010479111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ453402Medicare ID - Type Unspecified
NJT82455Medicare UPIN