Healthcare Provider Details

I. General information

NPI: 1033280367
Provider Name (Legal Business Name): STACEY BARBOSSA D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1637 JOHN F KENNEDY BLVD
JERSEY CITY NJ
07305-1865
US

IV. Provider business mailing address

1637 JOHN F KENNEDY BLVD
JERSEY CITY NJ
07305-1865
US

V. Phone/Fax

Practice location:
  • Phone: 201-435-0900
  • Fax: 201-435-0911
Mailing address:
  • Phone: 201-435-0900
  • Fax: 201-435-0911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number38MC00454600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: