1629461868 NPI number — JUSTIN JAMES DEPERMENTIER PT, DPT, ATC

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 1629461868 NPI number — JUSTIN JAMES DEPERMENTIER PT, DPT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEPERMENTIER
Provider First Name:
JUSTIN
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, ATC
Provider Gender Code:
M

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:
1629461868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 PARK WAY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BROOMALL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19008-4202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-422-8080
Provider Business Mailing Address Fax Number:
484-422-8073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 PARK WAY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BROOMALL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19008-4202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-355-1780
Provider Business Practice Location Address Fax Number:
484-428-3813
Provider Enumeration Date:
03/12/2015

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:  070.022242 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT024201 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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