Basic Information
| Provider Information | |||||||||
| NPI: | 1114255114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE PAIN REHAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 154 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080530154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092615755 | ||||||||
| FaxNumber: | 6092617199 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 WHITE HORSE RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080432494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095812700 | ||||||||
| FaxNumber: | 6092617199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2009 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOWEN | ||||||||
| AuthorizedOfficialFirstName: | JO | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6092615755 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 25MA06687200 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 25MA06687200 | 01 | NJ | NJ LICENSE | OTHER |