MEDICARE: DECOTIIS CHIROPRACTIC WELLNESS, 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	111N00000X	Chiropractor	38MC00636000	NJ

General Provider Information

NPI Number	:	1700107778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DECOTIIS CHIROPRACTIC WELLNESS, LLC

Provider Business Mailing Address
First Line	:	30 W HOLLY AVE
Second Line	:
City	:	PITMAN
State	:	NJ
Zip	:	08071-1405
Country	:	US
Telephone Number	:	856-218-1330
Fax Number	:	856-218-1332

Provider Business Practice Location Address
First Line	:	30 W HOLLY AVE
Second Line	:
City	:	PITMAN
State	:	NJ
Zip	:	08071-1405
Country	:	US
Telephone Number	:	856-218-1330
Fax Number	:	856-218-1332

Authorized Official
Title or Position	:	CEO/ OWNER
Name	:	DR. JOHN R DE COTIIS
Credential	:	D.C.
Telephone Number	:	856-218-1330

Provider Enumeration Date	:	06/14/2010
Last Update Date	:	06/14/2010

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