Healthcare Provider Details

I. General information

NPI: 1003064452
Provider Name (Legal Business Name): PROADVANTAGE PHYSICAL THERAPY INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WINSTON DR APT 119
CLIFFSIDE PARK NJ
07010-3209
US

IV. Provider business mailing address

200 WINSTON DR APT 119
CLIFFSIDE PARK NJ
07010-3209
US

V. Phone/Fax

Practice location:
  • Phone: 617-620-2137
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number40QA01242600
License Number StateNJ

VIII. Authorized Official

Name: YEVGENY FEDOSENKO
Title or Position: OWNER
Credential:
Phone: 617-620-2137