MEDICARE: MICHELLE VIEIRA PTA

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	310400000X	Assisted Living Facility	40QB00323100	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	40QB00323100	OTHER	NJ	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1790225365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE VIEIRA PTA

Provider Business Mailing Address
First Line	:	52 PINE DR
Second Line	:
City	:	CEDAR GROVE
State	:	NJ
Zip	:	07009-1036
Country	:	US
Telephone Number	:	862-216-0872
Fax Number	:

Provider Business Practice Location Address
First Line	:	52 PINE DR
Second Line	:
City	:	CEDAR GROVE
State	:	NJ
Zip	:	07009-1036
Country	:	US
Telephone Number	:	862-216-0872
Fax Number	:

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

Provider Enumeration Date	:	03/02/2017
Last Update Date	:	03/02/2017

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