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General NPI Number Information
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NPI Number | 1407165111
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Entity Type | Organization
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Legal Business Name | SPINE SPECIALIST
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Dates
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Enumeration Date | 09/29/2010
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Last Update Date | 05/04/2020
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Provider Practice Location Address
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Address Line | 1187 MAIN AVE STE 1D
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City | CLIFTON
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State | NJ
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Zip | 07011-2252
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Country | US
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Telephone | 973-742-0927
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Fax | 888-373-2114
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Provider Business Mailing Address
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Address Line | PO BOX 7036
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City | WEST ORANGE
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State | NJ
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Zip | 07052-7036
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Country | US
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Telephone | 973-742-0927
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Fax | 888-373-2114
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | MARCO ANTONIO LOPEZ
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Credential | DC
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Telephone | 973-742-0927
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NN0400X
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Taxonomy Name | Neurology Chiropractor
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License Number | X0116921
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 111NN0400X
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Taxonomy Name | Neurology Chiropractor
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License Number | 38MC00673900
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License Number State | NJ
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