Healthcare Provider Details

I. General information

NPI: 1619903234
Provider Name (Legal Business Name): DOMENIC FONTANAROSA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 12/18/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 LAFAYETTE AVENUE
HAWTHORNE NJ
07506
US

IV. Provider business mailing address

274 LAFAYETTE AVE
HAWTHORNE NJ
07506
US

V. Phone/Fax

Practice location:
  • Phone: 973-423-9600
  • Fax: 973-423-0403
Mailing address:
  • Phone: 973-423-9600
  • Fax: 973-423-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00443500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4435
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: