=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265820559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINCETON CHIROPRACTIC AND SPORTS REHAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2015
-----------------------------------------------------
Last Update Date | 01/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 EWING ST STE C3
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-2756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-921-1705
-----------------------------------------------------
Fax | 609-921-8871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 EWING ST STE C3
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-2756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-921-1705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDWARD SOFO
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 609-921-1705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 38MC00374900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------