Provider Demographics
NPI:1053741520
Name:MOBILE SPORTS CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:MOBILE SPORTS CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BRONDER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:973-851-9188
Mailing Address - Street 1:149 HORSENECK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-2306
Mailing Address - Country:US
Mailing Address - Phone:973-851-9188
Mailing Address - Fax:
Practice Address - Street 1:149 HORSENECK RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2306
Practice Address - Country:US
Practice Address - Phone:973-851-9188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00326100111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty