MEDICARE: MR. BOEMBOY M VENDIOLA

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	40QA01189500	NJ

General Provider Information

NPI Number	:	1689721862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BOEMBOY M VENDIOLA

Provider Business Mailing Address
First Line	:	432 CAMBRIDGE DR
Second Line	:
City	:	BUTLER
State	:	NJ
Zip	:	07405-3242
Country	:	US
Telephone Number	:	973-462-8548
Fax Number	:	201-794-6003

Provider Business Practice Location Address
First Line	:	401 HAMBURG TPKE STE 102
Second Line	:
City	:	WAYNE
State	:	NJ
Zip	:	07470-2139
Country	:	US
Telephone Number	:	201-794-2121
Fax Number	:

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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