Healthcare Provider Details

I. General information

NPI: 1609548932
Provider Name (Legal Business Name): JUSTIN BANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 JFK BLVD
WEST NEW YORK NJ
07093
US

IV. Provider business mailing address

2335 BLACKRIDGE DR
HOOVER AL
35244-5236
US

V. Phone/Fax

Practice location:
  • Phone: 201-758-0099
  • Fax:
Mailing address:
  • Phone: 404-579-0203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00781400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: