Provider Demographics
NPI:1356764492
Name:SM CHIROPRACTIC PC
Entity type:Organization
Organization Name:SM CHIROPRACTIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANGROK
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:201-410-9293
Mailing Address - Street 1:2460 LEMOINE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6210
Mailing Address - Country:US
Mailing Address - Phone:201-559-5307
Mailing Address - Fax:201-351-4787
Practice Address - Street 1:2460 LEMOINE AVE STE 203
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6210
Practice Address - Country:US
Practice Address - Phone:201-559-5307
Practice Address - Fax:201-351-4787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-25
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00081300171100000X
NJ38MC00648800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1184988107OtherNPI