1588618177 NPI number — CREST SPORTS TRNG PHYL THPY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588618177 NPI number — CREST SPORTS TRNG PHYL THPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREST SPORTS TRNG PHYL THPY
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:
1588618177
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 W GILBERT ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
RED BANK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07701-4918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-212-0060
Provider Business Mailing Address Fax Number:
732-212-0061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1904 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASQUAN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08736-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-212-0060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CALABRO
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
732-212-0060

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251X0800X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DE8996 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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