Healthcare Provider Details

I. General information

NPI: 1376888941
Provider Name (Legal Business Name): MLM CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133-B JACKSON RD
MEDFORD NJ
08055
US

IV. Provider business mailing address

133-B JACKSON RD
MEDFORD NJ
08055
US

V. Phone/Fax

Practice location:
  • Phone: 609-654-1330
  • Fax: 609-714-1612
Mailing address:
  • Phone: 609-654-1330
  • Fax: 609-714-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00557400
License Number StateNJ

VIII. Authorized Official

Name: DR. MICHAEL LANZILOTTA
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 609-654-1330