Healthcare Provider Details

I. General information

NPI: 1003771528
Provider Name (Legal Business Name): ERIC CANONACO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17-17 ROUTE 208 STE 116
FAIR LAWN NJ
07410-2819
US

IV. Provider business mailing address

17-17 ROUTE 208 STE 116
FAIR LAWN NJ
07410-2819
US

V. Phone/Fax

Practice location:
  • Phone: 201-291-0750
  • Fax: 201-291-0753
Mailing address:
  • Phone: 201-291-0750
  • Fax: 201-291-0753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA02392100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: