1710079454 NPI number — SPARTA ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC

Table of content: (NPI 1710079454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710079454 NPI number — SPARTA ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPARTA ORTHOPEDIC & SPORTS PHYSICAL THERAPY 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:
1710079454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
57 SPARTA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07871-1822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-726-0111
Provider Business Mailing Address Fax Number:
973-726-0399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 SPARTA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07871-1822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-726-0111
Provider Business Practice Location Address Fax Number:
973-726-0399
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THEURET
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT PHYSICAL THERAPIST
Authorized Official Telephone Number:
973-726-0111

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  40QA01006600 , 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)

  • Identifier: 611366300 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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