1164645917 NPI number — MARICHU MARCELO GAYTANO PHYSICAL THERAPIST

Table of content: MARICHU MARCELO GAYTANO PHYSICAL THERAPIST (NPI 1164645917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164645917 NPI number — MARICHU MARCELO GAYTANO PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAYTANO
Provider First Name:
MARICHU
Provider Middle Name:
MARCELO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

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:
1164645917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 EISENHOWER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAYREVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-651-1813
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625
Provider Second Line Business Practice Location Address:
ROUTE 34
Provider Business Practice Location Address City Name:
MATAWAN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-888-2453
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PTQA00718100 , 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)





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