=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952536054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONIA SPINE & WELLNESS CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2009
-----------------------------------------------------
Last Update Date | 05/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 PROSPECT LN SUITE 1D
-----------------------------------------------------
City | COLONIA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07067-3010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-827-0028
-----------------------------------------------------
Fax | 732-827-0018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 PROSPECT LN SUITE 1D
-----------------------------------------------------
City | COLONIA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07067-3010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-827-0028
-----------------------------------------------------
Fax | 732-827-0018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. GLENN A BAGER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 732-827-0028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00605200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------