Provider Demographics
NPI:1649832197
Name:SPINE & SPORTS MEDICINE OF LINCROFT, LLC
Entity type:Organization
Organization Name:SPINE & SPORTS MEDICINE OF LINCROFT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:732-714-0070
Mailing Address - Street 1:3 SWIMMING RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LINCROFT
Mailing Address - State:NJ
Mailing Address - Zip Code:07738-1725
Mailing Address - Country:US
Mailing Address - Phone:732-653-1000
Mailing Address - Fax:
Practice Address - Street 1:5 SWIMMING RIVER RD
Practice Address - Street 2:
Practice Address - City:LINCROFT
Practice Address - State:NJ
Practice Address - Zip Code:07738-1725
Practice Address - Country:US
Practice Address - Phone:324-514-5787
Practice Address - Fax:732-530-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-05
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty