=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770689176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PASSAIC CHIROPRACTIC & THERAPY CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 647 MAIN AVE SUITE 202
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-4934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-777-5400
-----------------------------------------------------
Fax | 973-777-5445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 647 MAIN AVE SUITE 202
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-4934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-777-5400
-----------------------------------------------------
Fax | 973-777-5445
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ALEXANDER DIMEO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 973-777-5400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00301100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------