Healthcare Provider Details

I. General information

NPI: 1629493945
Provider Name (Legal Business Name): LOGOS CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 MAIN ST
AVON BY THE SEA NJ
07717-1071
US

IV. Provider business mailing address

309 MAIN ST
TOMS RIVER NJ
08753-7409
US

V. Phone/Fax

Practice location:
  • Phone: 732-455-9936
  • Fax:
Mailing address:
  • Phone: 732-455-9936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00710400
License Number StateNJ

VIII. Authorized Official

Name: DR. DANIEL MUTTER
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 732-455-9936