=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063902716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED THERAPEUTICS CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2018
-----------------------------------------------------
Last Update Date | 05/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 764 EASTON AVE STE 5
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08873-1856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-640-0725
-----------------------------------------------------
Fax | 732-640-0724
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 764 EASTON AVE STE 5
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08873-1856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-640-0725
-----------------------------------------------------
Fax | 732-640-0724
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MANAGER
-----------------------------------------------------
Name | DR. MICHAELENE CALLAHAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 732-640-0725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00609100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------