Basic Information
| Provider Information | |||||||||
| NPI: | 1952536054 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLONIA SPINE & WELLNESS CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 PROSPECT LN | ||||||||
| Address2: | SUITE 1D | ||||||||
| City: | COLONIA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070673010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328270028 | ||||||||
| FaxNumber: | 7328270018 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 PROSPECT LN | ||||||||
| Address2: | SUITE 1D | ||||||||
| City: | COLONIA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070673010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328270028 | ||||||||
| FaxNumber: | 7328270018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2009 | ||||||||
| LastUpdateDate: | 05/19/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAGER | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIROPRACTOR | ||||||||
| AuthorizedOfficialTelephone: | 7328270028 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 38MC00605200 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.