Provider Demographics
NPI:1952337529
Name:MOUNTAINSIDE WELLNESS, LLC
Entity Type:Organization
Organization Name:MOUNTAINSIDE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TOTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-236-4701
Mailing Address - Street 1:512 ELIAS AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-2208
Mailing Address - Country:US
Mailing Address - Phone:732-236-4701
Mailing Address - Fax:
Practice Address - Street 1:1139 SPRUCE DR
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-2221
Practice Address - Country:US
Practice Address - Phone:908-233-3993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00617100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U8GMedicare UPIN
NJ099746Medicare ID - Type Unspecified