Healthcare Provider Details

I. General information

NPI: 1578501524
Provider Name (Legal Business Name): ADVANCED PHYSICAL MEDICINE & REHABILATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 STATE HIGHWAY 88
BRICK NJ
08724-3049
US

IV. Provider business mailing address

1645 STATE HIGHWAY 88
BRICK NJ
08724-3049
US

V. Phone/Fax

Practice location:
  • Phone: 732-202-1200
  • Fax: 732-202-1300
Mailing address:
  • Phone: 732-202-1200
  • Fax: 732-202-1300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberMC003514
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4OQAO1152600
License Number StateNJ

VIII. Authorized Official

Name: DR. PETER ANTHONY DENINO JR.
Title or Position: PARTNER
Credential: D.C.
Phone: 732-202-1200