Provider Demographics
NPI:1952536054
Name:COLONIA SPINE & WELLNESS CENTER PA
Entity Type:Organization
Organization Name:COLONIA SPINE & WELLNESS CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BAGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-827-0028
Mailing Address - Street 1:15 PROSPECT LN
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-3010
Mailing Address - Country:US
Mailing Address - Phone:732-827-0028
Mailing Address - Fax:732-827-0018
Practice Address - Street 1:15 PROSPECT LN
Practice Address - Street 2:SUITE 1D
Practice Address - City:COLONIA
Practice Address - State:NJ
Practice Address - Zip Code:07067-3010
Practice Address - Country:US
Practice Address - Phone:732-827-0028
Practice Address - Fax:732-827-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00605200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty