=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003043852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW URBAN CHIROPRACTIC GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2009
-----------------------------------------------------
Last Update Date | 06/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 UNION AVE SUITE # 705
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-371-2011
-----------------------------------------------------
Fax | 973-371-2062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 UNION AVE SUITE # 705
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-371-2011
-----------------------------------------------------
Fax | 973-371-2062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MR. KENNETH BURGESS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-371-2011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00427700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------