MEDICARE: BERGEN SPINE CENTER, 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	38MC00653900	NJ

General Provider Information

NPI Number	:	1750509402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERGEN SPINE CENTER, LLC

Provider Business Mailing Address
First Line	:	323 BERGEN BOULEVARD
Second Line	:
City	:	FAIRVIEW
State	:	NJ
Zip	:	07022-1334
Country	:	US
Telephone Number	:	201-945-9993
Fax Number	:	201-945-8873

Provider Business Practice Location Address
First Line	:	323 BERGEN BOULEVARD
Second Line	:
City	:	FAIRVIEW
State	:	NJ
Zip	:	07022-1334
Country	:	US
Telephone Number	:	201-945-9993
Fax Number	:	201-945-8873

Authorized Official
Title or Position	:	DOCTOR OF CHIROPRACTIC
Name	:	DR. JOSEPH STEPHAN
Credential	:	D.O.
Telephone Number	:	201-945-9993

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	08/22/2020

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