Provider Demographics
NPI:1952425621
Name:INNOVATIVE SPINE CARE, LLC
Entity Type:Organization
Organization Name:INNOVATIVE SPINE CARE, LLC
Other - Org Name:PURE ANTI AGING MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARAHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-444-0020
Mailing Address - Street 1:1144 E RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3915
Mailing Address - Country:US
Mailing Address - Phone:201-444-0020
Mailing Address - Fax:201-444-0026
Practice Address - Street 1:18 W RIDGEWOOD AVE FL 2
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2333
Practice Address - Country:US
Practice Address - Phone:201-444-0020
Practice Address - Fax:201-444-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07099100111NR0400X, 207R00000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty