=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407929904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED SPINE AND REHABILITATION CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 04/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 E BROAD ST
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-327-2100
-----------------------------------------------------
Fax | 856-327-1113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 E BROAD ST
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-327-2100
-----------------------------------------------------
Fax | 856-327-1113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARTIN HAHN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 856-327-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00611700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------