Basic Information
| Provider Information | |||||||||
| NPI: | 1417293051 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187670610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 776 N RTE 17 | ||||||||
| Address2: | |||||||||
| City: | PARAMUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076523108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014441177 | ||||||||
| FaxNumber: | 2014441933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/01/2013 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AGRELO | ||||||||
| AuthorizedOfficialFirstName: | HELEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIR OF BUS. OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7187670610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY PC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.