Provider Demographics
NPI:1356874168
Name:JERSEY SPINE AND WELLNESS, LLC
Entity type:Organization
Organization Name:JERSEY SPINE AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMISH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-255-1910
Mailing Address - Street 1:35 BEAVERSON BLVD
Mailing Address - Street 2:BLDG 12 STE B
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723
Mailing Address - Country:US
Mailing Address - Phone:732-255-1910
Mailing Address - Fax:732-255-1930
Practice Address - Street 1:2446 CHURCH RD
Practice Address - Street 2:SUITE 2E
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8182
Practice Address - Country:US
Practice Address - Phone:732-255-1910
Practice Address - Fax:732-255-1930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00732000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty