Healthcare Provider Details

I. General information

NPI: 1861887630
Provider Name (Legal Business Name): GARDEN STATE SPINE AND PAIN CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 CLIFTON AVE SUITE 203
CLIFTON NJ
07013-3519
US

IV. Provider business mailing address

1 TREETOP CT
BERKELEY HEIGHTS NJ
07922-2531
US

V. Phone/Fax

Practice location:
  • Phone: 862-335-9696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number25MA08823500
License Number StateNJ

VIII. Authorized Official

Name: SUKDEB DATTA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 615-479-4692