Healthcare Provider Details

I. General information

NPI: 1891333431
Provider Name (Legal Business Name): PETRIS CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 LAKEHURST RD FL 1
TOMS RIVER NJ
08755-8044
US

IV. Provider business mailing address

551 LAKEHURST RD FL 1
TOMS RIVER NJ
08755-8044
US

V. Phone/Fax

Practice location:
  • Phone: 732-678-6785
  • Fax:
Mailing address:
  • Phone: 732-678-6785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP PETRIS
Title or Position: CHIROPRACTOR/OWNER
Credential: DC
Phone: 732-678-6785