=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407010291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLEXWELLNESS OF TETERBORO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2008
-----------------------------------------------------
Last Update Date | 07/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HOLLISTER RD
-----------------------------------------------------
City | TETERBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07608-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-288-5400
-----------------------------------------------------
Fax | 201-288-5402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 624
-----------------------------------------------------
City | TOTOWA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07511-0624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-844-1155
-----------------------------------------------------
Fax | 973-844-1133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. FRANK NICOSIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-844-1155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00574800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------