Healthcare Provider Details

I. General information

NPI: 1639492507
Provider Name (Legal Business Name): THE RANDOLPH PAIN RELIEF CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 03/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

588 ROUTE 10 W
RANDOLPH NJ
07869-2056
US

IV. Provider business mailing address

588 ROUTE 10 W
RANDOLPH NJ
07869-2056
US

V. Phone/Fax

Practice location:
  • Phone: 973-366-6615
  • Fax:
Mailing address:
  • Phone: 973-366-6615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DAVID J SIMON
Title or Position: MANAGING MEMBER
Credential: DC
Phone: 973-366-6615