=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306160122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JERSEY CHIROPRACTIC AND WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2010
-----------------------------------------------------
Last Update Date | 03/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 W MAIN ST SUITE 202
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834-2174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-625-7800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 W MAIN ST SUITE 202
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834-2174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-625-7800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JERSEY WULSTER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 973-625-7800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00260800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------