Healthcare Provider Details

I. General information

NPI: 1215395132
Provider Name (Legal Business Name): PRIME SPINECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 BROAD AVE STE N9
PALISADES PARK NJ
07650-2721
US

IV. Provider business mailing address

118 BROAD AVE STE N9
PALISADES PARK NJ
07650-2721
US

V. Phone/Fax

Practice location:
  • Phone: 201-482-0439
  • Fax: 201-482-8703
Mailing address:
  • Phone: 201-482-0439
  • Fax: 201-482-8703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00733100
License Number StateNJ

VIII. Authorized Official

Name: DR. CHANG PARK
Title or Position: MD/PRESIDENT
Credential:
Phone: 201-482-0439