Healthcare Provider Details

I. General information

NPI: 1851548762
Provider Name (Legal Business Name): CLIFTON SPORTS MEDICINE & PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 MAIN AVE
CLIFTON NJ
07011-2241
US

IV. Provider business mailing address

1233 MAIN AVE
CLIFTON NJ
07011-2241
US

V. Phone/Fax

Practice location:
  • Phone: 973-595-6444
  • Fax:
Mailing address:
  • Phone: 973-595-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00619200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00630100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number25MB06381000
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number40QA01282900
License Number StateNJ

VIII. Authorized Official

Name: DR. PETER PONZINI
Title or Position: MANAGER
Credential: D.C.
Phone: 973-595-6444