Healthcare Provider Details

I. General information

NPI: 1609787993
Provider Name (Legal Business Name): ANTHONY A BOLOGNINI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5-05 SADDLE RIVER RD
FAIR LAWN NJ
07410-5633
US

IV. Provider business mailing address

10 2ND ST
BLOOMFIELD NJ
07003-2322
US

V. Phone/Fax

Practice location:
  • Phone: 201-429-3214
  • Fax:
Mailing address:
  • Phone: 201-905-4421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT00067500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: