=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396922340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CHIROPRACTIC CENTER OF NEW JERSEY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2008
-----------------------------------------------------
Last Update Date | 02/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8325 KENNEDY BLVD
-----------------------------------------------------
City | NORTH BERGEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07047-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-861-2025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8325 KENNEDY BLVD
-----------------------------------------------------
City | NORTH BERGEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07047-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-861-2025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALEJANDRO M HERNANDEZ
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 201-861-2025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 38MC00622100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------