=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033227004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTE FOR DIAGNOSIS & TREATMENT OF PAIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 08/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33-00 BROADWAY SUITE # 209
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-4617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-796-7666
-----------------------------------------------------
Fax | 201-796-5570
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33-00 BROADWAY SUITE # 209
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-4617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-796-7666
-----------------------------------------------------
Fax | 201-796-5570
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MARINA PRAKHINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-796-7666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA068923
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------