Healthcare Provider Details

I. General information

NPI: 1275050619
Provider Name (Legal Business Name): TALARIA PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2017
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 UNION AVE STE 200
CRESSKILL NJ
07626-2137
US

IV. Provider business mailing address

56 JACKSON AVE
HAWORTH NJ
07641-1450
US

V. Phone/Fax

Practice location:
  • Phone: 201-588-6290
  • Fax: 201-588-6059
Mailing address:
  • Phone: 201-588-6290
  • Fax: 201-588-6059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01409300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number40QA01409300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number40QA01409300
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number40QA01409300
License Number StateNJ

VIII. Authorized Official

Name: DR. DEMETRI E. DIMITRIADIS
Title or Position: OWNER
Credential: PT, DPT
Phone: 201-588-6290