Basic Information
| Provider Information | |||||||||
| NPI: | 1366002651 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRINCETON BRAIN SPINE AND SPORTS MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 558 LAWRENCE SQUARE BLVD S | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086482674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095856100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 558 LAWRENCE SQUARE BLVD S | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086482674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099219001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2019 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | QUILLE | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6095856100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.