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NPI Code Detail

MEDICARE: THEA OMEGA JARDINIANO DELA CUESTA P.T.

MEDICARE: THEA OMEGA JARDINIANO DELA CUESTA P.T.
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
1225100000XPhysical Therapist40QA01055700NJ

General Provider Information

NPI Number : 1619187424
Entity Type Code : Individual
Provider Name (Legal Business Name) : THEA OMEGA JARDINIANO DELA CUESTA P.T.
Provider Business Mailing Address
First Line : 482 LAWRENCE ST
Second Line :
City : MAYWOOD
State : NJ
Zip : 07607-1260
Country : US
Telephone Number : 201-880-6258
Fax Number :
Provider Business Practice Location Address
First Line : 125 WASHINGTON AVE
Second Line :
City : DUMONT
State : NJ
Zip : 07628-3066
Country : US
Telephone Number : 201-385-6272
Fax Number : 201-385-7410
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2007
Last Update Date : 07/08/2007

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