1588855308 NPI number — MRS. ELIZABETH BULOSAN DIVINAGRACIA PHYSICAL THERAPIST

Table of content: MRS. ELIZABETH BULOSAN DIVINAGRACIA PHYSICAL THERAPIST (NPI 1588855308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588855308 NPI number — MRS. ELIZABETH BULOSAN DIVINAGRACIA PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIVINAGRACIA
Provider First Name:
ELIZABETH
Provider Middle Name:
BULOSAN
Provider Name Prefix Text:
MRS.
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:
BULOSAN
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
VILLASENOR
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICAL THERAPIST
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588855308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 ROSE COURT 2ND FOR
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-993-9344
Provider Business Mailing Address Fax Number:
201-433-4772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 POST RD STE M12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07436-1615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-651-0062
Provider Business Practice Location Address Fax Number:
201-651-7723
Provider Enumeration Date:
08/06/2007

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: 111NR0400X , with the licence number:  40QA00953000 , 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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