=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780036590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALL CITY SPINE AND HEALTH CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2016
-----------------------------------------------------
Last Update Date | 07/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 UNION AVE SUITE 305
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-3277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-260-3476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 UNION AVE SUITE 305
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-3277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-260-3476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. EMMANUEL MARIE RENAUDO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 203-260-3476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 28MA008569300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00703500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------