Basic Information
| Provider Information | |||||||||
| NPI: | 1184754434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELLACE | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACH | ||||||||
| OtherFirstName: | JAIME | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 801 N KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080341513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774073422 | ||||||||
| FaxNumber: | 8774074329 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 KINGS HWY N | ||||||||
| Address2: | FOX REHABILITATION | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080341513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774073422 | ||||||||
| FaxNumber: | 8774074329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA00900800 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00198898 | 01 | NJ | RAILROAD MEDICARE | OTHER |