MEDICARE: MS. KRYSTYNA MACIEJAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1255926713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRYSTYNA MACIEJAK

Provider Business Mailing Address
First Line	:	615 SPRUCE ST
Second Line	:
City	:	LINDEN
State	:	NJ
Zip	:	07036-5035
Country	:	US
Telephone Number	:	908-486-9089
Fax Number	:

Provider Business Practice Location Address
First Line	:	623 RIDGE RD
Second Line	:
City	:	LYNDHURST
State	:	NJ
Zip	:	07071-3205
Country	:	US
Telephone Number	:	201-340-4656
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2021
Last Update Date	:	03/06/2021

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