Healthcare Provider Details

I. General information

NPI: 1932278207
Provider Name (Legal Business Name): MARK WERNEKE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W MAIN ST
FREEHOLD NJ
07728-2537
US

IV. Provider business mailing address

248 NEWARK AVE
LAVALLETTE NJ
08735-2830
US

V. Phone/Fax

Practice location:
  • Phone: 732-294-2700
  • Fax:
Mailing address:
  • Phone: 732-830-1378
  • Fax: 732-294-2568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00248200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: