=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861907180
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDEN STATE SPINAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2017
-----------------------------------------------------
Last Update Date | 12/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 BRIGHTON RD STE 304
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07012-1665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-570-8491
-----------------------------------------------------
Fax | 973-860-2434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 BRIGHTON RD STE 304
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07012-1665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 973-860-2434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | DR. JENNIFER CATHERINE DOUR
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 732-570-8491
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00655600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------