NPIMap

Organization Active NPI

Spine & Sports Medicine of Tinton Falls LLC

  • Interventional Pain Medicine Physician
  • Tinton Falls, NJ
National Provider Identifier
1801315635
Registry record updated May 9, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Pain Medicine PhysicianTaxonomy code 208VP0014X
Legal business name
SPINE & SPORTS MEDICINE OF TINTON FALLS LLC
Practice address
4057 Asbury Ave Ste 4
Tinton Falls, NJ 07753-7700
Phone
(732) 333-3099
Fax
(848) 217-7463
NPI assigned
Sep 13, 2017
Last updated
May 9, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 9, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Nicole Fullaway, DPTNPI 1235442690
Title
Owner
Phone
(609) 505-9090

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
ChiropractorGroup: 193200000X MULTI-SPECIALTY GROUP 111N00000X
AcupuncturistGroup: 193200000X MULTI-SPECIALTY GROUP 171100000X
Orthopaedic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207X00000X
Physical Medicine & Rehabilitation PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208100000X
Interventional Pain Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208VP0014X Primary
Physical TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225100000X

Addresses

Primary practice location

4057 Asbury Ave Ste 4
Tinton Falls, NJ 07753-7700

Mailing address

4057 Asbury Ave
Store #4
Tinton Falls, NJ 07753-7700
Phone (732) 333-3099

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NJ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20180319000698 NJ Part B Supplier - Clinic/Group Practice 9931461696 Receives reassigned benefits from 15 practitioners
Practice locations: Tinton Falls, NJ
O20181109000081 NJ DME Supplier - Physician - General Practice 9931461696 Practice locations: Tinton Falls, NJ

National Provider Directory

National Provider Directory

Locations

4057 Asbury Ave
Ste 4
Tinton Falls, NJ 07753
Phone (732) 333-3099

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1505260800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715212800000",
    "number": "1801315635",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4057 ASBURY AVE",
            "address_2": "STORE #4",
            "city": "TINTON FALLS",
            "state": "NJ",
            "postal_code": "077537700",
            "telephone_number": "732-333-3099"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4057 ASBURY AVE STE 4",
            "city": "TINTON FALLS",
            "state": "NJ",
            "postal_code": "077537700",
            "telephone_number": "732-333-3099",
            "fax_number": "848-217-7463"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPINE & SPORTS MEDICINE OF TINTON FALLS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-13",
        "last_updated": "2024-05-09",
        "certification_date": "2024-05-09",
        "status": "A",
        "authorized_official_last_name": "FULLAWAY",
        "authorized_official_first_name": "NICOLE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "609-505-9090",
        "authorized_official_credential": "DPT"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "171100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Acupuncturist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0014X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tinton Falls, NJ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.