MEDICARE: PRINCETON CHIROPRACTIC AND SPORTS REHAB, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	38MC00374900	NJ

General Provider Information

NPI Number	:	1265820559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCETON CHIROPRACTIC AND SPORTS REHAB, LLC

Provider Business Mailing Address
First Line	:	601 EWING ST STE C3
Second Line	:
City	:	PRINCETON
State	:	NJ
Zip	:	08540-2756
Country	:	US
Telephone Number	:	609-921-1705
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 EWING ST STE C3
Second Line	:
City	:	PRINCETON
State	:	NJ
Zip	:	08540-2756
Country	:	US
Telephone Number	:	609-921-1705
Fax Number	:	609-921-8871

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EDWARD SOFO
Credential	:	D.C.
Telephone Number	:	609-921-1705

Provider Enumeration Date	:	01/08/2015
Last Update Date	:	01/08/2015

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