MEDICARE: SPARTA ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC

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	40QA01006600	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	611366300	OTHER	NJ	DEPARTMENT OF LABOR

General Provider Information

NPI Number	:	1710079454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARTA ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	57 SPARTA AVE
Second Line	:
City	:	SPARTA
State	:	NJ
Zip	:	07871-1822
Country	:	US
Telephone Number	:	973-726-0111
Fax Number	:	973-726-0399

Provider Business Practice Location Address
First Line	:	57 SPARTA AVE
Second Line	:
City	:	SPARTA
State	:	NJ
Zip	:	07871-1822
Country	:	US
Telephone Number	:	973-726-0111
Fax Number	:	973-726-0399

Authorized Official
Title or Position	:	PRESIDENT PHYSICAL THERAPIST
Name	:	MR. SCOTT C THEURET
Credential	:	RPT
Telephone Number	:	973-726-0111

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	07/28/2016

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