MEDICARE: JOSEPH J LICITRA DC

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	38MC00224400	NJ

General Provider Information

NPI Number	:	1891795514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH J LICITRA DC

Provider Business Mailing Address
First Line	:	300 BROADACRES DR STE 126A
Second Line	:
City	:	BLOOMFIELD
State	:	NJ
Zip	:	07003-3153
Country	:	US
Telephone Number	:	973-470-0632
Fax Number	:	973-893-8259

Provider Business Practice Location Address
First Line	:	300 BROADACRES DR STE 126
Second Line	:
City	:	BLOOMFIELD
State	:	NJ
Zip	:	07003-3153
Country	:	US
Telephone Number	:	973-470-0632
Fax Number	:	973-893-8259

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	09/16/2022

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