MEDICARE: SPINE AND SPORTS THERAPY OF NEW JERSEY PC

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

General Provider Information

NPI Number	:	1356840524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE AND SPORTS THERAPY OF NEW JERSEY PC

Provider Business Mailing Address
First Line	:	1 JOURNAL SQUARE PLZ STE 303
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-4004
Country	:	US
Telephone Number	:	914-376-6100
Fax Number	:	914-470-5056

Provider Business Practice Location Address
First Line	:	1 JOURNAL SQUARE PLZ STE 303
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-4004
Country	:	US
Telephone Number	:	914-376-6100
Fax Number	:	914-470-5056

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MELISSA NIELI
Credential	:
Telephone Number	:	914-376-6100

Provider Enumeration Date	:	02/02/2018
Last Update Date	:	02/02/2018

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