Healthcare Provider Details

I. General information

NPI: 1215995030
Provider Name (Legal Business Name): SPINE AND PAIN CENTERS, P. A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1967 STATE ROUTE 34 STE 102
WALL TOWNSHIP NJ
07719-9738
US

IV. Provider business mailing address

1967 STATE ROUTE 34 STE 102
WALL TOWNSHIP NJ
07719-9738
US

V. Phone/Fax

Practice location:
  • Phone: 732-345-1180
  • Fax: 732-530-4476
Mailing address:
  • Phone: 732-345-1180
  • Fax: 732-530-4476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM DONALD
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 732-345-1180