Healthcare Provider Details

I. General information

NPI: 1336656461
Provider Name (Legal Business Name): BACK AND BODY PAIN RELIEF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 ROUTE 22 STE D
SPRINGFIELD NJ
07081-3511
US

IV. Provider business mailing address

355 ROUTE 22 STE D
SPRINGFIELD NJ
07081-3511
US

V. Phone/Fax

Practice location:
  • Phone: 908-325-3000
  • Fax: 908-325-3232
Mailing address:
  • Phone: 908-325-3000
  • Fax: 908-325-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAN SIVENDRA
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 908-325-3000