MEDICARE: JOSEPH LICITRA DC 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

General Provider Information

NPI Number	:	1902520109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSEPH LICITRA DC LLC

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 126A
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	:	OWNER
Name	:	JOSEPH LICITRA
Credential	:	DC
Telephone Number	:	201-247-5363

Provider Enumeration Date	:	09/30/2022
Last Update Date	:	09/30/2022

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