Healthcare Provider Details

I. General information

NPI: 1033353438
Provider Name (Legal Business Name): BAYONNE PEDIATRIC THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 BROADWAY
BAYONNE NJ
07002-2522
US

IV. Provider business mailing address

252 BROADWAY
BAYONNE NJ
07002-2522
US

V. Phone/Fax

Practice location:
  • Phone: 201-436-0014
  • Fax: 201-436-0019
Mailing address:
  • Phone: 201-436-0014
  • Fax: 201-436-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number46TR00070400
License Number StateNJ

VIII. Authorized Official

Name: DR. KRIS MAMMAS
Title or Position: PRESIDENT
Credential: DVM
Phone: 201-436-0014