1316099310 NPI number — JOHNS ORTHOPEDIC & SHOE REPAIR LLC

Table of content: PATRICK COTTER MA, MPT, DPT (NPI 1417097130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316099310 NPI number — JOHNS ORTHOPEDIC & SHOE REPAIR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNS ORTHOPEDIC & SHOE REPAIR 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:
1316099310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
929 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYONNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07002-3050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-339-8750
Provider Business Mailing Address Fax Number:
201-455-2606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
929 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYONNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07002-3050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-339-8750
Provider Business Practice Location Address Fax Number:
201-455-2606
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
URRUTIA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
SOLE MBR/OWNER
Authorized Official Telephone Number:
201-339-8750

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8087202 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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