Healthcare Provider Details

I. General information

NPI: 1710039623
Provider Name (Legal Business Name): CORNERSTONE PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 CENTRAL AVE 2ND FLOOR
CLARK NJ
07066
US

IV. Provider business mailing address

152 CENTRAL AVE 2ND FLOOR
CLARK NJ
07066
US

V. Phone/Fax

Practice location:
  • Phone: 732-499-4540
  • Fax: 732-499-4577
Mailing address:
  • Phone: 732-499-4540
  • Fax: 732-499-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01170400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number40QA01170400
License Number StateNJ

VIII. Authorized Official

Name: MR. DAVID DE LA FUENTE
Title or Position: PHYSICAL THERAPIST, PRESIDENT
Credential: MS, PT, CSCS
Phone: 732-499-4540