Healthcare Provider Details

I. General information

NPI: 1013456680
Provider Name (Legal Business Name): PRECISION SPORTS AND SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1091 US HIGHWAY 9 POWERHOUSE GYM OF OLD BRIDGE C/O PRECISION SPINE
OLD BRIDGE NJ
08857-2877
US

IV. Provider business mailing address

105 SULESKI CT
MAHWAH NJ
07430-2961
US

V. Phone/Fax

Practice location:
  • Phone: 201-994-9782
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00647700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01449100
License Number StateNJ

VIII. Authorized Official

Name: STEVEN MARINKOVIC
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 201-994-9782