Healthcare Provider Details

I. General information

NPI: 1952463267
Provider Name (Legal Business Name): BRICK PAIN RELIEF AND WELLNESS, INST.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 ROUTE 88
BRICK NJ
08724-3265
US

IV. Provider business mailing address

2095 ROUTE 88
BRICK NJ
08724-3265
US

V. Phone/Fax

Practice location:
  • Phone: 732-899-5400
  • Fax: 732-899-9288
Mailing address:
  • Phone: 732-899-5400
  • Fax: 732-899-9288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberMC2602
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMB53521
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberQA01049100
License Number StateNJ

VIII. Authorized Official

Name: WILLIAM WALSH
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 732-899-5400