| Organization Name: | PERFORMANCE SPINE AND SPORTS MEDICINE OF BORDENTOWN, LLC |
| NPI Number: | 1073912333 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MATTHIAS HEINZ WIEDERHOLZ (OWNER) |
| Mailing Address: | 9500 K. Johnson Blvd Suite 1 Bordentown |
| State: | NJ US |
| Postal Code: | 085054400 |
| Phone Number: | 6095888600 |
| Fax Number: | 6095888602 |
| NPI Enumeration Date: | 08/22/2014 |
| NPI Last Update Date: | 08/22/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | 25MA08436100 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NJ |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |