MEDICARE: SPINE AND SPORTS REHAB. INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	38MC00311800	NJ

General Provider Information

NPI Number	:	1952472458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE AND SPORTS REHAB. INSTITUTE

Provider Business Mailing Address
First Line	:	1800 STATE ROUTE 34
Second Line	:	BLDGE # 3
City	:	WALL
State	:	NJ
Zip	:	07719-9168
Country	:	US
Telephone Number	:	732-223-5550
Fax Number	:	732-280-0233

Provider Business Practice Location Address
First Line	:	1800 STATE ROUTE 34
Second Line	:	BLDGE # 3
City	:	WALL
State	:	NJ
Zip	:	07719-9168
Country	:	US
Telephone Number	:	732-223-5550
Fax Number	:	732-280-0233

Authorized Official
Title or Position	:	OWNER
Name	:	GUY DONNER
Credential	:	D.C.
Telephone Number	:	732-223-5550

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	08/22/2020

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