1790338036 NPI number — FUNCTIONALMAX CUSTOMIZED PHYSICAL THERAPY

Table of content: NATALIE LAURA WATROUS OT (NPI 1578247656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790338036 NPI number — FUNCTIONALMAX CUSTOMIZED PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONALMAX CUSTOMIZED PHYSICAL THERAPY
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:
1790338036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
241 W PASSAIC ST APT 10B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHELLE PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07662-3116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-388-4790
Provider Business Mailing Address Fax Number:
609-435-1234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
241 W PASSAIC ST APT 10B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHELLE PARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07662-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-388-4790
Provider Business Practice Location Address Fax Number:
609-435-1234
Provider Enumeration Date:
07/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ARRUFFAT
Authorized Official First Name:
MANUEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
201-293-0753

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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