=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407589682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNATE RESTORATIVE HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2022
-----------------------------------------------------
Last Update Date | 07/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 BROADWAY
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-3627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-486-2150
-----------------------------------------------------
Fax | 609-486-2149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 CHINGARORA AVE
-----------------------------------------------------
City | KEYPORT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07735-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-887-3881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | ALYSSA J RIVERS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 732-887-3881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------