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General NPI Number Information
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NPI Number | 1194060392
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Entity Type | Organization
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Legal Business Name | DIVINE CHIROPRACTIC CENTER, LLC
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Dates
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Enumeration Date | 11/29/2012
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Last Update Date | 11/29/2012
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Provider Practice Location Address
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Address Line | 221 KEARNY AVE
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City | KEARNY
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State | NJ
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Zip | 07032-2437
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Country | US
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Telephone | 973-494-4533
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4
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City | BELLEVILLE
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State | NJ
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Zip | 07109-0004
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Country | US
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Telephone | 973-494-4533
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. KATHLEEN CALIXTO
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Credential | DC
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Telephone | 973-494-4533
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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 | 38MC00638600
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License Number State | NJ
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