Healthcare Provider Details

I. General information

NPI: 1871043182
Provider Name (Legal Business Name): SPINE AND SPORTS MEDICINE OF MANCHESTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 LACEY RD
WHITING NJ
08759-2921
US

IV. Provider business mailing address

60 LACEY RD
WHITING NJ
08759-2921
US

V. Phone/Fax

Practice location:
  • Phone: 732-408-4492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number25MB09673700
License Number StateNJ

VIII. Authorized Official

Name: MATTHEW LEGOWSKI
Title or Position: OPERATIONS
Credential:
Phone: 609-703-5097