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General NPI Number Information
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NPI Number | 1063880011
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Entity Type | Organization
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Legal Business Name | MINIMALLY INVASIVE AND REGENERATIVE SPINE INSTITUTE
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Dates
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Enumeration Date | 09/08/2015
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Last Update Date | 09/08/2015
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Provider Practice Location Address
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Address Line | 1054 CLIFTON AVE
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City | CLIFTON
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State | NJ
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Zip | 07013-3638
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Country | US
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Telephone | 973-779-4100
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Fax |
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Provider Business Mailing Address
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Address Line | 1054 CLIFTON AVE
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City | CLIFTON
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State | NJ
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Zip | 07013-3638
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Country | US
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Telephone | 973-779-4100
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Fax |
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Authorized Official
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Title or Position | SOLE MBR
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Name | TOMI PRVULOVIC
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Credential | M.D.
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Telephone | 973-903-4943
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 25MA06129800
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License Number State | NJ
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