Healthcare Provider Details

I. General information

NPI: 1356764492
Provider Name (Legal Business Name): SM CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2014
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 LEMOINE AVE STE 203
FORT LEE NJ
07024-6210
US

IV. Provider business mailing address

2460 LEMOINE AVE STE 203
FORT LEE NJ
07024-6210
US

V. Phone/Fax

Practice location:
  • Phone: 201-559-5307
  • Fax: 201-351-4787
Mailing address:
  • Phone: 201-559-5307
  • Fax: 201-351-4787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00648800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00081300
License Number StateNJ

VIII. Authorized Official

Name: SANGROK MOON
Title or Position: PRESIDENT
Credential: DC, L.AC.
Phone: 201-410-9293