Healthcare Provider Details

I. General information

NPI: 1578506986
Provider Name (Legal Business Name): JOHN R DE COTIIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W HOLLY AVE
PITMAN NJ
08071-1405
US

IV. Provider business mailing address

PO BOX 210
PITMAN NJ
08071-0210
US

V. Phone/Fax

Practice location:
  • Phone: 856-218-1330
  • Fax: 856-218-1332
Mailing address:
  • Phone: 856-218-1330
  • Fax: 856-218-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00636000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: