Healthcare Provider Details

I. General information

NPI: 1780254862
Provider Name (Legal Business Name): EDGE WELLNESS AND PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 EXECUTIVE DR STE C1
FORT LEE NJ
07024-3308
US

IV. Provider business mailing address

80 E RTE 4 STE 100
PARAMUS NJ
07652-2647
US

V. Phone/Fax

Practice location:
  • Phone: 201-785-7486
  • Fax: 201-771-3024
Mailing address:
  • Phone: 201-845-3000
  • Fax: 201-843-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAWRENCE KIM
Title or Position: CEO
Credential: PT, DPT, OCS
Phone: 201-785-7486