Healthcare Provider Details

I. General information

NPI: 1114466901
Provider Name (Legal Business Name): NORTHEASTERN SPINE & PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 ROUTE 94 UNIT#2
HAMBURG NJ
07419-9651
US

IV. Provider business mailing address

3621 ROUTE 94 UNIT#2
HAMBURG NJ
07419-9651
US

V. Phone/Fax

Practice location:
  • Phone: 973-864-8997
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. VINCENT CAVALLARO
Title or Position: OWNER
Credential:
Phone: 845-699-2342