=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932419918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY ESTRADA D.C,
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2010
-----------------------------------------------------
Last Update Date | 10/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 VAN HOUTEN AVE
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-5518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 551-795-0831
-----------------------------------------------------
Fax | 973-282-8584
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 BOLL ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07014-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 551-795-0831
-----------------------------------------------------
Fax | 973-282-8584
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00682200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------