Provider Demographics
NPI:1801315635
Name:SPINE & SPORTS MEDICINE OF TINTON FALLS LLC
Entity type:Organization
Organization Name:SPINE & SPORTS MEDICINE OF TINTON FALLS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:609-505-9090
Mailing Address - Street 1:4057 ASBURY AVE
Mailing Address - Street 2:STORE #4
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-7700
Mailing Address - Country:US
Mailing Address - Phone:732-333-3099
Mailing Address - Fax:
Practice Address - Street 1:4057 ASBURY AVE STE 4
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07753-7700
Practice Address - Country:US
Practice Address - Phone:732-333-3099
Practice Address - Fax:848-217-7463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty