1871962175 NPI number — PURSUE PHYSICAL THERAPY & PERFORMANCE TRAINING

Table of content: (NPI 1871962175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871962175 NPI number — PURSUE PHYSICAL THERAPY & PERFORMANCE TRAINING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURSUE PHYSICAL THERAPY & PERFORMANCE TRAINING
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:
1871962175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
271 GROVE AVE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERONA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07044-1729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-340-4846
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
271 GROVE AVE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERONA
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07044-1729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-340-4846
Provider Business Practice Location Address Fax Number:
973-513-6105
Provider Enumeration Date:
09/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CRUZ
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
973-271-3368

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  25MZ00129400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251S0007X , with the licence number: 40QA01514700 , 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: 1134580988 . This is a "NPI- JASON PARK" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1407273642 . This is a "NPI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1447684642 . This is a "NPI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1033612163 . This is a "ACUPUNCTURE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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