Healthcare Provider Details

I. General information

NPI: 1285079590
Provider Name (Legal Business Name): PARK PLACE CHIROPRACTIC AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 ACADEMY ST
NEWARK NJ
07102-2923
US

IV. Provider business mailing address

17 ACADEMY ST
NEWARK NJ
07102-2923
US

V. Phone/Fax

Practice location:
  • Phone: 973-824-2225
  • Fax: 973-824-5454
Mailing address:
  • Phone: 973-824-2225
  • Fax: 973-824-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberMC03260
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number38MCOO326000
License Number StateNJ

VIII. Authorized Official

Name: DR. GARY STEPAN BOZIAN
Title or Position: PRESIDENT
Credential: DC
Phone: 973-824-2225