Healthcare Provider Details

I. General information

NPI: 1346480712
Provider Name (Legal Business Name): MINNELLA PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 BUCHANAN AVE
EDGEWATER PARK NJ
08010-2109
US

IV. Provider business mailing address

217 BUCHANAN AVE
EDGEWATER PARK NJ
08010-2109
US

V. Phone/Fax

Practice location:
  • Phone: 973-919-4862
  • Fax: 866-699-1796
Mailing address:
  • Phone: 973-919-4862
  • Fax: 866-699-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number40QA01021500
License Number StateNJ

VIII. Authorized Official

Name: DR. LEWIS M MINNELLA
Title or Position: PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 973-919-4862