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General NPI Number Information
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NPI Number | 1114097367
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Entity Type | Organization
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Legal Business Name | LAKEWOOD WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 10/17/2008
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Provider Practice Location Address
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Address Line | 1700 MADISON AVE
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City | LAKEWOOD
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State | NJ
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Zip | 08701-1253
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Country | US
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Telephone | 732-363-7900
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Fax |
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Provider Business Mailing Address
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Address Line | 1700 MADISON AVE
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City | LAKEWOOD
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State | NJ
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Zip | 08701-1253
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Country | US
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Telephone | 732-363-7900
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. STUART JEFFREY PODOB
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Credential | D.C.
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Telephone | 732-363-7900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 38MC00649200
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License Number State | NJ
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