1093855322 NPI number — GARDEN STATE PHYSICAL THERAPY AND WELLNESS CENTER LLC

Table of content: (NPI 1093855322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093855322 NPI number — GARDEN STATE PHYSICAL THERAPY AND WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDEN STATE PHYSICAL THERAPY AND WELLNESS CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093855322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 N BROAD ST STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07208-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-354-1511
Provider Business Mailing Address Fax Number:
908-659-9229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 N BROAD ST STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07208-2310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-354-1511
Provider Business Practice Location Address Fax Number:
908-659-9229
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANGLE
Authorized Official First Name:
OLFEA
Authorized Official Middle Name:
DIGAMON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
908-354-1511

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  40QA00504100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001590204 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3K4126 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P3440262 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: Q23Q61 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: Q23Q61 . This is a "EMPIRE BLUE CROSS/BS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0000-225-0032-04 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 687933 . This is a "ACN GROUP" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 44902 . This is a "ORTHONET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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