Healthcare Provider Details

I. General information

NPI: 1407079833
Provider Name (Legal Business Name): HARBORSIDE SPORT & SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 MONTGOMERY ST SUITE 603
JERSEY CITY NJ
07302-3726
US

IV. Provider business mailing address

75 MONTGOMERY ST SUITE 603
JERSEY CITY NJ
07302-3726
US

V. Phone/Fax

Practice location:
  • Phone: 201-433-1955
  • Fax:
Mailing address:
  • Phone: 201-433-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberMC00641600
License Number StateNJ

VIII. Authorized Official

Name: DR. DAVID SYLVESTER
Title or Position: SINGLE MEMBER
Credential: DC
Phone: 201-433-1955