Healthcare Provider Details

I. General information

NPI: 1861304545
Provider Name (Legal Business Name): JORGE MANUEL QUISPE SANDOVAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 BROAD ST
CLIFTON NJ
07013-3346
US

IV. Provider business mailing address

141 OLD SHORT HILLS RD APT 15
WEST ORANGE NJ
07052-1066
US

V. Phone/Fax

Practice location:
  • Phone: 973-574-8585
  • Fax:
Mailing address:
  • Phone: 973-513-2658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00434300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: