=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144550104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALLINGTON CHIROPRACTIC CENTER P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2010
-----------------------------------------------------
Last Update Date | 01/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 436 MAIN AVE
-----------------------------------------------------
City | WALLINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07057-1830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-365-1700
-----------------------------------------------------
Fax | 973-365-1788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 436 MAIN AVE
-----------------------------------------------------
City | WALLINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07057-1830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-365-1700
-----------------------------------------------------
Fax | 973-365-1788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. FERNANDO BARRESE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 973-365-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 38MC00596300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------